Summary

[Fistula] is a condition that denied me the chance to enjoy
my life as a young person. I was isolated and rejected. All my nights were
nights of shedding tears due to genital sores. I carried the condition for 12
years without knowing that I could be treated here in Kenya.... I made several
attempts to take my life and was admitted to [a] mental ward.… In May
2007 a successful surgery was done.… The closure of that hole is not all
that these women need. After I was operated on, I was returned to the mental
ward again. You realize, I am not dead, but I am not living.

—Amolo
A., a Kenya woman who had a successful fistula repair and is a community
educator on fistula, Nairobi, November 26, 2009

Medically fistula is caused by obstructed labor. But also
there is obstructed transport, obstructed family planning, obstructed emergency
care, obstructed rights.… Everything is obstructed.

Tens of thousands of women and girls around
the world suffer every year from obstetric fistula, a preventable childbirth
injury that results in urine and/or stool incontinence. Fistula causes
infections, pain, and bad smell, and often triggers stigma and the breakdown of
family, work, and community life.

The full global extent of this problem is not known.
According to the World Health Organization, fistula strikes roughly 50,000 to
100,000 women and girls every year, mainly in resource poor countries in
sub-Saharan Africa and Asia. In Kenya approximately 3,000 women and girls
develop fistula every year, while the backlog of those living with untreated
fistula is estimated to be between 30,000 and 300,000 cases. There are many
doubts about these estimates because few studies have been conducted to
establish the extent of this problem in the country. Fistula sufferers are
mostly young women and girls with little education. They often come from remote
and poor areas where infrastructure is underdeveloped and access to health care,
particularly emergency obstetric care, is lacking.

A woman who develops fistula has already gone through the
trauma of a long, painful obstructed labor. In most cases, the labor ends with
a stillbirth. As the woman begins to recover from the grief and agony of the failed
delivery, she discovers that her body is painfully damaged. She might think
that she is suffering from temporary, somewhat normal incontinence. But then
she begins to smell, her clothing and bedding are constantly wet, her thighs
sting, and she might develop ulcers on her vagina. At first, the woman might
try to hide her condition, but usually this is impossible. Sex is painful, and
her marriage, as a result, might start to fray or even turn violent. She might
be thrown out by her husband, her relatives and friends may think that she is
bewitched or cursed. In all likelihood, she will stop working, going to market,
and participating in social or religious life. She might live in pain and
isolation for years, even decades, before learning that surgery could fix her
condition. This news will not be enough for many the fistula survivors who lack
the resources and autonomy to pursue surgery. For some, however, surgery
provides a chance for a new life.

The Kenyan state violates the rights of fistula sufferers in
multiple ways, by denying them their internationally-guaranteed access to the
highest attainable standard of health, to health information critical to women’s
and girls’ wellbeing, to their reproductive and maternal health, and to a
remedy for the injustices and denial of service that they face. Kenya, as a
party to numerous international and regional human rights instruments such as
the International Covenant on Economic, Social and Cultural Rights (ICESCR),
the Convention on the Elimination of All Forms of Discrimination against Women
(CEDAW), and the African Charter on Human and Peoples’ Rights (African
Charter), is obligated to act to rectify these violations and to eliminate the
discrimination that both contributes to the disabling condition of fistula and
results from it.

This report is based on field research conducted by Human
Rights Watch in November and December 2009 in hospitals in Kisumu, Nairobi, Kisii,
and Machakos as well as in Dadaab in March 2010. We interviewed 55 women and
girls ranging in age from 14 to 73 years, 53 of whom had fistula. Of the 53
with fistula, twelve were girls aged 14-18 years. We also interviewed nine
obstetric fistula surgeons, one anesthetist, three hospital administrators, and
nine nurses working in hospital gynecology and labor wards, five of whom worked
in fistula wards. We interviewed four secondary and four primary school
teachers regarding sexuality education in schools. Further, we talked to
nongovernmental organizations working on health and women’s rights,
government officials, professional associations for doctors and nurses,
international donors, United Nations representatives, and an elected councilor
representing a ward in Machakos.

Reproductive and maternal health care are considered top
development and human rights priorities. The UN Committee on Economic, Social
and Cultural rights has identified the lowering of maternal mortality, and
morbidity such as obstetric fistula, as a “major goal” for
governments in meeting their human rights obligations. Under the
Millennium Development Goals, governments have committed to improve maternal
and reproductive health through a 75 per cent reduction in the maternal
mortality ratio from 1990 levels, and achieving universal access to
reproductive health by 2015.

The Kenya government has taken some positive steps to
improve women’s and girls’ reproductive and maternal health. These initiatives
include eliminating charges for public family planning services, antenatal and
postnatal care, and prevention of mother-to-child HIV transmission. The
government has also eliminated charges for delivery in dispensaries and health
centers to encourage women to deliver in medical facilities with a skilled
birth attendant. In addition, by introducing a system of full or partial fee
waiver for access to government hospitals, the government has taken steps to
increase access to health care for indigent patients. However, as this report
shows through the voices of fistula survivors, many women and girls, particularly
the poor, illiterate, and rural, are not fully enjoying the benefit of these
policies, and there is urgent need to reevaluate and scale up many of the
responses.

The report discusses five areas that require increased attention
in order to improve maternal health care and reduce obstetric fistulas: access
to family planning information and services, the provision of school-based
sexuality education, access to emergency obstetric care including referral and
transport systems, overcoming economic barriers to maternal health care
services and fistula treatment, and health system accountability.

Women and girls need access to information to make informed choices
about their sexual and reproductive lives. They also need information about access
to services which help ensure a healthy pregnancy and delivery, and for treating
obstetric complications such as fistula. Yet information on reproductive
health, family planning, potential complications during pregnancy and
childbirth, the advantages of facility deliveries, what fistula is, and the
availability and cost of fistula treatment and maternity-related services are
all lacking among many of the women and girls we interviewed, and even among
some health providers.

For example, 20-year-old Kwamboka W. became pregnant at age
13 while in primary school, developed fistula, and lived with it for seven
years before hearing on the radio about a United Nations Population Fund (UNFPA)
funded fistula repair camp offering free surgeries. She told us, “I
didn’t know anything about family planning or condoms. I just went once
and got pregnant. I still have no idea about contraceptives.” Despite
some government efforts to introduce sexuality education in upper primary and
secondary schools, Kenya has not made it part of the official syllabus and as a
result there is no time allocated within school hours to teach it.

In 2004, the government conducted a fistula needs assessment
that showed lack of awareness about fistula in communities as a barrier to its
prevention and treatment. Six years later, the government has not taken
adequate steps to educate the population, nor to correct the myths that exist
about fistula in many communities.

The Kenya government’s efforts to ensure affordable
maternity care for poor rural women and girls have fallen far short of even its
own goals. Upwards of three quarters of the women and girls interviewed by
Human Rights Watch described economic constraints as a barrier to accessing
maternal health services and fistula repair surgery. Almost all women and girls
interviewed for this report told Human Rights Watch how difficult it was to raise
the money needed for fistula surgery. To its credit, the government supports
donor-funded fistula repair “camps”—consisting of short-term
mobilization of women and girls, screening for obstetric fistula, and providing
surgery for those affected—in district and provincial hospitals around
the country several times a year. These camps offer free repair surgeries, but
do not cover all associated costs. In addition, government hospitals offer
exemptions and waivers for indigent patients, but these policies have been
problematic in practice.

The health user fee waiver policy does not work for several
reasons: lack of awareness of the policy among patients and some health
providers, some facilities’ reluctance to publicize the waivers and
deliberate withholding of information when requested by patients, and vague
implementation guidelines, including the criteria for determining the financial
needs of a patient. Many women and girls living with fistula are poor, but none
we spoke to had received a waiver.

Women with obstructed labor, which can lead to fistula, need
emergency obstetric care such as Cesarean sections. Inadequate access to
emergency obstetric care, especially for poor and rural women, is a
longstanding problem in Kenya. Kenyan government statistics have shown that capacity
to manage complications during childbirth is weak in many health facilities, including
referral facilities such as hospitals. Currently available statistics show that
less than 10 percent of all medical facilities in the country are able to offer
basic emergency obstetric care, and only 6 percent offer comprehensive
emergency obstetric care.

In order to correct systemic failures in reducing maternal deaths
and obstetric fistula, it is important to get feedback from patients on the
quality and acceptability of services provided. But accountability mechanisms,
which should serve the purpose of identifying systemic problems in
Kenya’s health system, are far from effective. There should be accessible
ways of providing such feedback, lodging complaints, and ensuring such feedback
is acted upon. Real accountability mechanisms would not only enhance trust in
the health system but also improve utilization and success of maternal health
services.

Most of the women Human Rights Watch interviewed did not
know how, or to whom, they could complain about or challenge any of the above
barriers. Nor did they have any faith that complaints would result in improved
treatment. They were also afraid of retaliation by health staff if they
complained. We found no indication that the government had taken any steps to
enable illiterate patients to understand their rights and to lodge grievances.

While fistula surgery is increasingly available, the
government and organizations providing repair surgeries have paid little
attention to the long-term needs of women and girls for physical, emotional,
psychological, and economic support after surgery. There are no formal
initiatives by the government or other service providers to rehabilitate and
reintegrate fistula survivors into families and communities. Fistula survivors
have endured social and psychological torment that is unlikely to end with
surgery. Women may continue to be stigmatized even after successful repair due
to lack of fistula awareness in communities, and unsuccessful repairs can be
traumatizing for women. Further, fistula places a heavy financial burden on
survivors and their families, and as a result they may need support to become
economically productive after repair.

The World Health Organization has developed important
recommendations for clinical management of obstetric fistula, as well as
program development to address issues of fistula prevention and rehabilitation.
However, Kenya has not developed a national strategy to address fistula despite
conducting a needs assessment in 2004. The WHO recommends that national strategies
to address obstetric fistula be integrated into existing programs on safe
motherhood and those to improve maternal and neonatal health generally, but
Kenya is not adequately doing this.

Key Recommendations to the Kenyan Government

Develop and implement a national fistula strategy in
accordance with the World Health Organization’s “Obstetric Fistula:
Guiding Principles for Clinical Management and Programme Development.” Relevant
government ministries, such as the Ministry of Gender and Children Affairs and
the two ministries of health, and NGOs should participate in crafting the
strategy.

Carry out an awareness-raising campaign to inform the public
about the causes of fistula, contributing factors (such as female genital
mutilation and early marriage and childbearing), the need for facility
deliveries, and the availability of treatment. Involve provincial
administrators, religious leaders, and NGOs in the campaign.

Integrate information on fistula into the community strategy
by training community health extension workers and community health workers to educate
communities about fistula and to identify and refer for treatment women and
girls with fistula.

Expand the Community Midwifery Model to cover the whole
country and address payment of community midwives.

Urgently improve the financial accessibility of fistula
surgery by subsidizing routine repairs in provincial and district hospitals,
including follow-up visits, and providing free fistula surgeries for indigent
patients.

Urgently improve the quality of and access to emergency
obstetric care by:

increasing the number of health facilities that offer emergency
obstetric care;

developing and implementing guidelines on the management
of obstructed labor and the management of women who present with obstetric
fistula immediately after birth or who present with an established fistula
requiring repair;

implementing the referral component of the Community
Strategy; and

completing and implementing the referral strategy.

Assess the possibility of an exemption from user fees for all
maternal health care, beyond the current exemption for childbirth in
dispensaries and health centers.

Methodology

This report is based on interviews conducted in November and
December 2009 in Kisii, Machakos, Kisumu, Nairobi and Dadaab in March 2010. Our
research included visits to three public hospitals that were holding fistula
repair camps, and a mission hospital in Nairobi that does routine fistula
operations.[1] We also
visited several dispensaries and health centers in Machakos and Kisumu.

Because of the difficulty of finding women and girls living
with fistula to interview within their communities, we opted to use the fistula
camps at hospitals since they presented the opportunity to interview many women
and girls from across regional and ethnic backgrounds in one setting. We
received immense cooperation and support from the gynecologists who were
organizing the fistula treatment camps, and they were our main gateway to
reaching women and girls in the hospitals.

We interviewed 55 women and girls ranging in age from 14 to
73 years old—12 were girls aged 14-18 years—53 of whom had fistula.[2]
Of these, 35 were waiting to undergo fistula repair surgery, 13 had gone
through surgery and were recovering in the hospital, and five had come for
review following surgery. We also interviewed two women at Machakos General
Hospital who were detained for failure to pay hospital charges following
complications during pregnancy. Interviews were semi-structured and covered a
range of topics related to fistula and maternal health care. We also
interviewed nine obstetric fistula surgeons, one anesthetist, three hospital
administrators, and nine nurses working in hospital gynecology and labor wards,
five of whom worked in fistula wards. Further, we talked to nongovernmental organizations
working on health and women’s rights, government officials, professional
associations for doctors and nurses, international donors, United Nations
representatives, and an elected councilor representing a ward in Machakos.

On the subject of sexuality education in schools, Human
Rights Watch interviewed four secondary school teachers and four primary school
teachers.

Because of the sensitive nature of obstetric fistula, we
were mindful not to re-traumatize women and girls we interviewed. Before each
interview, we informed interviewees of its purpose, voluntary nature, the kind
of issues that would be covered, and the ways in which the data would be used.
The interviewees verbally consented to be interviewed. Further verbal consent
was given to record the interviews. Women and girls were told that they could
decline to answer questions, could take a break, or could end the interview at
any time without consequence.We took great care to interview women and girls in a sensitive
manner, and ensured that the interview took place in a comfortable and private
setting.

We have changed all the names of women and girls interviewed
to pseudonyms in order to protect their privacy. The identities of some other
interviewees have also been withheld at their request.

Participants did not receive any material compensation from
Human Rights Watch.
In order to avoid false expectations of financial assistance or
support, we made it clear at the start of each interview that we were not able
to provide direct individual support to those who spoke with us. When we
encountered situations where women and girls were in need of psychological or
other medical support, we referred them to local NGOs or others who could
assist them.

Interviews were carried out in English and Kiswahili without
interpretation and in Kikamba and Dholuo with the assistance of interpreters.
All the translators were female health professionals who understood the
sensitivity of interviewing fistula survivors.

Human Rights Watch also reviewed research and reports by
national and international health and human rights organizations and UN
agencies, as well as government policies and statistics on health care in
Kenya.

The report also uses material from an obstetric fistula
stakeholders meeting organized by the Department of Reproductive Health in the
Ministry of Public Health and Sanitation, attended by the Human Rights Watch
researcher. The meeting was held on February 4, 2010, and brought together a
range of health providers working on obstetric fistula: fistula surgeons and
nurses, hospital administrators, government officials, and representatives from
the United Nations and non-governmental organizations working on obstetric
fistula.

I. Background

Maternal Mortality and
Morbidity Globally

Most obstetric complications and deaths are preventable. The
causes of maternal deaths and morbidities and the most effective ways of
preventing and treating them have been recognized for many years.[3]
Yet, hundreds of thousands of women and girls die every year as a result of
preventable and treatable complications during pregnancy, childbirth, or the
six weeks following delivery. Estimates on the number of women who die vary.
According to estimates developed by the World Health Organization, UNICEF,
UNFPA, and the World Bank, over half a million maternal deaths occur globally
each year.[4]
A 2010 analysis of maternal mortality for 181 countries shows an estimated
342,900 maternal deaths occurred in 2008.[5]
Measuring maternal mortality is challenging at best, but the latest available
trend data indicate that the global maternal mortality ratio (MMR) declined
from 320 per 100,000 live births in 1990 to 251 in 2008.[6]

The numbers of women and girls who die do not reveal the
full scale of this tragedy. For every woman or girl who dies as a result of
pregnancy or childbirth, about 30 more suffer short or long-term injury,
infection, or disabilities (maternal morbidities).[7]

The magnitude of global maternal mortality and morbidity and
the profile of those most heavily affected reveal chronic and entrenched health
inequalities both between and within countries. First, the burden of maternal
mortality and morbidity is borne disproportionately by developing countries,
mainly those in sub-Saharan Africa.[8]
Second, in many countries, preventable maternal deaths and morbidities more
often affect distinct groups of women and girls, such as rural, low-income,
ethnic minority, or indigenous women and girls. This is the case even in
countries with low maternal mortality ratios. Finally, maternal mortality and
morbidity ratios are often indicative of inequalities between men and women in
their enjoyment of the right to health.[9]

The last two decades have seen increased international and
regional efforts to combat maternal mortality and morbidity. At the
international level, the most significant of these is the Millennium
Declaration in 2000, when 189 countries pledged
to achieve eight development goals (the Millennium Development Goals or MDGs)
by 2015, including a 75 percent maternal mortality reduction compared to 1990
levels.[10]
In June 2009, the United Nations Human Rights Council adopted a landmark
resolution on “preventable maternal mortality and morbidity and human
rights,” which calls on states to renew their political commitment to
eliminating preventable maternal mortality and morbidity at the local,
national, regional, and international levels, including through the allocation
of necessary domestic resources to health systems.[11]In September 2008, the European Parliament passed a
resolution on maternal mortality calling upon the European Union to commit to
reducing maternal and newborn mortality and morbidity both at home and abroad.[12]
In April 2010, the UN Secretary-General announced the development of a Joint
Action Plan to accelerate progress toward achieving the MDGs dealing with
maternal and child health.[13]

In 2004, all health ministers of the African Union, with
support from World Health Organization Africa Regional Office, the United
Nations Population Fund (UNFPA), and the United Nations Children’s Fund
(UNICEF), adopted “The African Road Map for Accelerating the Attainment
of the MDGs related to maternal and newborn health” (MNH Road Map).[14]
Its objectives are “to provide skilled attendance during pregnancy,
childbirth, and the postnatal period, at all levels of the health care delivery
system, and … [to] strengthen the capacity of individuals, families and
communities to improve MNH.”[15]
Countries are expected to adopt and to develop national MNH Road Maps to scale
up responses to reduce maternal and neonatal mortality and morbidity. According
to UNFPA, as of July 2009 more than 40 sub-Saharan African countries had
developed national MNH Road Maps and the majority of them were implementing
them,[16]
but only eight countries had developed national strategies to address obstetric
fistula as a specific subset of maternal health concerns.[17]

Following on this initiative, in 2006 African Heads of State
adopted the Maputo Plan of Action (MPoA), which sets out a framework for
countries to improve women’s and girls’ reproductive and maternal
health.[18]
In 2009, the African Union launched a campaign for accelerated reduction of
maternal mortality in Africa, with the slogan “Africa Cares: No Woman
should Die While Giving Life.” The campaign is meant to help countries
achieve the goals of the MPoA.[19]

Fistula Globally

Fistula has virtually been eliminated in developed countries
but is still common in the developing world. There are no worldwide,
comprehensive surveys that estimate the incidence and prevalence of obstetric
fistula. Currently available data by the World Health Organization (WHO)
indicate that between 50,000 and 100,000 women and girls are affected each
year.[20]
This is widely viewed as an underestimate as it is based on numbers of people
who sought care in hospitals and clinics, while many women with fistula do not
seek care. Fistula tends to happen to the most marginalized in society: poor
and illiterate young women and adolescent girls from rural areas.[21]
Consequently, fistula has largely remained a hidden condition. Many women who
develop fistula have stillbirths, contributing to neonatal mortality in
countries where they are predominant.[22]

Causes of Fistula

Obstetric fistula is predominantly caused by prolonged
obstructed labor, which is one of the five major causes of maternal mortality
and accounts for 8 percent of maternal deaths worldwide.[23]
During the prolonged obstructed labor, the soft tissues of the birth canal are
compressed between the descending head of the fetus and the woman’s
pelvic bone. The lack of blood flow causes tissue to die, creating a hole
(fistula) between the woman’s vagina and bladder (vesico-vaginal fistula
or VVF) or between the vagina and rectum (recto-vaginal fistula or RVF) or
both. This leaves the woman leaking urine and/or feces continuously from the
vagina. Other direct causes of fistula include sexual abuse and rape, surgical
trauma (iatrogenic fistula), and gynecological cancers and related radiotherapy
treatment.

Most fistulas can be repaired surgically even if they are
several years old. Success rates for fistula repair by experienced surgeons can
be as high as 90 percent, according to UNFPA.[24]
Successful surgery can enable women to live normal lives and even have
children, but it is recommended to have a Cesarean section for future
deliveries to prevent the fistula from recurring.

Early Marriage

Early marriage, marriage before the age of 18 years, is
considered a major risk factor for fistula development.[25]
Adolescent girls are particularly susceptible to obstructed labor because their
pelvises are not fully developed.[26]
Early marriage is associated not only with early childbearing, but also with
reduced school attendance. This contributes to illiteracy, poverty, and low
status in the community. Further, married girls and child mothers face
constrained decision-making, including reproductive and maternity care choices,
because they are often controlled by their husbands and relatives.[27]
Kenya’s Children’s Act prohibits marriage before age 18.[28]
Nonetheless, the 2008-09 Kenya Demographic and Health Survey (KDHS) shows that 24.6
percent of Kenyan women aged 20-24 had been married by age 18.[29]

Female Genital Mutilation

Female genital mutilation (FGM) can also contribute to
fistula occurrence, especially in communities that practice type three female
circumcision or infibulation.[30] In many
cases of infibulations, the woman is cut during childbirth to allow exit of the
fetal head. This is sometimes done by unskilled traditional birth attendants
who use razors or arrowheads to perform bilateral upper episiotomies, which may
inadvertently extend to the bladder or rectum, causing a fistula. In Nigeria,
the “gishiri” cut, a form of FGM similar to infibulation, is
commonly practiced amongst the Hausa people. In Nigeria, 15 percent of
obstetric fistulas are caused by this harmful practice.[31]
FGM is outlawed in Kenya, but some communities still practice it.[32]
Infibulation is common in North Eastern Kenya and parts of Rift Valley among
the West Pokot. FGM prevalence in these regions is 97.5 percent and 32.1
percent, respectively. This is markedly higher than the 27 percent Kenyan
average.[33]

International Response
to Fistula

There is growing global momentum by international agencies
to address the problem of obstetric fistula. In 2003, UNFPA and partners
launched a global Campaign to End Fistula with the target to eliminate fistula
by 2015, in line with the Millennium Development Goal to improve maternal
health. The global campaign focuses on prevention, treatment, and rehabilitation,
and has been launched in 47 countries in Africa, Asia, and the Middle East.[34]
Recognizing the lack of reliable data on fistula, one of its objectives is to
conduct country-level situation analyses, including fistula prevalence,
although challenges remain in collecting accurate data.[35]
EngenderHealth, through its Fistula Care Project and with funding from the
United States Agency for International Development (USAID), the UK Department
for International Development (DFID), and the Bill & Melinda Gates
Foundation, works on fistula prevention and treatment in 11 countries, mainly
in Africa.[36]
In 2006, the World Health Organization developed guidelines for obstetric
fistula clinical management and program development to guide comprehensive
country responses to fistula.[37]

In February 2008, the General Assembly for the first time adopted
a resolution on “supporting efforts to end obstetric fistula,” and
called on states, the United Nations, and international financial institutions,
as well as civil society organizations, to support efforts to address fistula.[38]
The resolution also requested the UN Secretary-General to report to the General
Assembly on the implementation of the resolution. In August 2008, the
Secretary-General presented a report detailing efforts to address fistula at
the national, regional, and international levels, and recommendations to
intensify efforts to end fistula.[39]

Key Data on Maternal
Health and Fistula in Kenya

Kenya’s maternal mortality ratio, according to the 2008-09
Kenya Demographic and Health Survey, is 488 maternal deaths per 100,000 live
births.[40]
Maternal deaths represent 15 percent of all deaths to women of reproductive age
(15-49 years). Between 294,000 and 441,000 Kenyan women and girls suffer from
maternal morbidities.[41]The majority of deaths are due to direct obstetric complications,
including hemorrhage, sepsis, eclampsia, and obstructed labor, or to unsafe
abortion.[42]
Unsafe abortion alone is thought to cause at least a third of all maternal
deaths.[43]
The government had set targets of having the MMR at 230 by 2005, and 170 by the
end of 2010.[44]

Although there has been some increase in contraceptive use
in Kenya, the unmet need is still high, with wide regional variations.[45]
Less than half—46 percent—of married women are using some method of
family planning, and only 39 percent are using modern methods.[46]
The unmet need is higher for women in rural areas.[47]The total fertility rate has slightly reduced from 4.9 children
per woman in 2003 to 4.6 in 2008 according to the current Kenya Demographic and
Health Survey.[48]
There are wide differentials by region and education status. The total
fertility rate for women in rural areas (5.2 births) is almost double that of
women in urban areas (2.9 births), while that for women with at least some
secondary education is 3.1, compared to 6.7 for women with no education.[49]
These statistics point to gaps in the provision of family planning education
and services to illiterate and rural women (discussed in more detail below).

About 92 percent of women receive some antenatal care,
though take-up of antenatal care is less likely in rural areas.[50]
Only 47 percent of pregnant women receive the recommended four or more
antenatal visits (while only 15 percent visit within the first trimester), a
decline from 52 percent in the 2003 KDHS.[51]
Most deliveries take place at home: only 44 percent of women deliver with a
skilled birth attendant and 43 percent of such deliveries take place in a
health facility.[52]
Traditional birth attendants assist in 28 percent of home deliveries.[53]

In 2004, the Ministry of Health and UNFPA conducted a needs
assessment of obstetric fistula in Kenya, marking the first major step taken by
the government to address obstetric fistula. The 2004 research indicated that
fistula affects approximately 3,000 women and girls every year (calculated at
the rate of one to two cases per 1,000 deliveries). This needs assessment
estimated that there is a backlog of up to 300,000 untreated fistula cases.[54]
Doubts exist about these estimates; some experts think that the prevalence
could be higher while others argue that some progress has been made both in
terms of repairing existing cases and in improving access to maternity care.
Therefore the prevalence could be lower.[55]

Relevant Policies

To its credit, the Kenyan government has taken positive
steps to address maternal mortality and morbidity by developing various
strategies, policies, and guidelines to address women’s reproductive and
maternal health. Few of these expressly address obstetric fistula, however.

The strategies, policies, and guidelines most relevant to
fistula are described in detail in Appendix 1. They include several on
reproductive health (the National Reproductive Health Strategy and the National
Reproductive Health Policy); family planning (the Family Planning Guidelines
for Service Providers); adolescent health (the Adolescent Reproductive Health
and Development Policy and the National Guidelines for Provision of
Youth-Friendly Services); and on reconfiguring health care delivery services to
better serve poor and rural communities (including the National Health Sector
Strategic Plan, the Kenya Essential Package for Health, the Community Strategy,
and the Community Midwifery Approach).

While there is no national strategy on fistula, in 2006 the
Ministry of Health did issue the “Kenya National Obstetric Fistulae
Training Curriculum for Health Care Workers.”[56]
The curriculum is a helpful tool for doctors, nurses, and other medical and
social workers involved in managing fistula, but is far from a national policy
or strategy.

Two of the efforts to revamp health care delivery in Kenya
that are most relevant to fistula are the Community Strategy and the Community
Midwifery Approach. Both have experienced serious delays and difficulties in
implementation; if these are overcome, the strategies could reduce many of the
barriers to information and to effective care which contribute to
fistula’s prevalence.

Community Strategy

In 2006 the Ministry of
Health launched the Community Strategy, which has been lauded as a viable
approach to improve service delivery at the lowest levels of the health care
system (community level or level one) that serve mainly rural and poor
communities. It envisages building the capacity of households not only to demand
services from all health providers, but to know and progressively realize their
rights to equitable, good quality health care. The strategy aims, among other
things, to reduce child and maternal deaths.[57]Three categories of services should be provided
at the community level: disease prevention and control to reduce morbidity,
disability and mortality; hygiene and environmental sanitation; and family
health services to expand family planning, maternal, child, and youth services.[58]
There are two categories of personnel promoting health at the community level:
community health workers (CHWs) who work on a volunteer basis, and community
health extension workers (CHEWs) who are paid government employees and
supervise CHWs.

One focus area in the Community Strategy is to address
challenges related to decision-making for maternity care, which contribute to
delay in seeking skilled care in case of complications.[59]
Many Kenyan women and girls have these decisions made for them by husbands or
mothers-in-law, or other relatives. This occurs for several reasons, including
the low status of women in society, poverty, and illiteracy, as demonstrated by
Kenyan health survey work.[60] Part of
the Strategy includes educating men about safe motherhood, and training women
to speak out about their needs, components which are not currently being
fulfilled.[61]
Approaches have been insufficiently sensitive to gender power differentials,
according to those who have evaluated outcomes thus far.[62]

Profile of Kanyua L.: family decision to delay seeking care led to
fistula, Machakos, December 6, 2009.

“I
started labor on a Saturday at about 6 p.m., and immediately told my
mother-in-law. I told her to take me to hospital but she said ‘the
nurses just tell you to go and deliver in a hospital but there is nothing
wrong in delivering at home. I delivered all my children safely at home and
so will you.’ I did not say anything to her because when one is sick
you do not take yourself to hospital. You follow what others tell you. My
mother-in-law left and came back with a traditional birth attendant (TBA).
The TBA examined me and said all was well, and that I would deliver in a few
hours. She told my mother-in-law to keep an eye on me, and to call her when
the baby’s head appears, then she left. I was in so much pain the whole
night. My mother-in-law went for the TBA the following day around 2 p.m. The
TBA examined me by putting her hands in my birth canal and said I had dilated
well. She kept asking me to push. I pushed but the baby did not come out. This
continued until about 11 p.m. when my husband said we should go to hospital.
However, we couldn’t get a vehicle because it was at night. In the
morning, we went to Wote dispensary and they said the baby was dead. They
took me to Machakos Hospital. At Machakos, I was operated on to remove the
dead baby. Two days later, I realized water [urine] was just coming
out.”

Personnel and resource challenges
have dogged implementation of the Community Strategy as well, including low
motivation of CHWs because they are not paid, inadequate training of CHWs in
key messages, and service providers’ poor understanding of the essential
services package concept.[63]Community
health extension workers and Community Health workers are trained on a range of
reproductive health issues, including how to refer women for obstetric care.
They are not trained on fistula.[64]

The Community Strategy presents an opportunity to reach
communities with information on fistula, to identify women living with fistula,
and to refer them for treatment. CHEWs and CHWs can help to collect useful data
on fistula in communities as well. Data on fistula is not collected routinely
in health facilities, nor is there analysis of its causes. The 2008-09 Kenya
Demographic and Health Survey—which focused on reproductive
health—failed to collect conclusive data on fistula although UNFPA had
provided money for this purpose.[65]
Data collection is an essential component of accountability, which, as will be
shown further on, is critical to ensure that these rights violations are
remedied.[66]

Community Midwifery Approach

In 2005 the Department of Reproductive Health in what is now
the Ministry of Public Health and Sanitation, the Population Council, and the
Nursing Council of Kenya developed and piloted the Community Midwifery Approach
(CMA) in an effort to increase skilled attendance at birth and reduce obstetric
complications.[67]
The CMA involves identifying health professionals who meet certain
qualifications who are then given training on technical developments to be able
to provide home-based skilled attendance at delivery and essential newborn and
postpartum care.[68]

Community midwives are not government employees but they are
formally linked to government health facilities and supervised by a government
employee: the District Public Health Nurse. They depend entirely on community
members’ ability to pay them for the services provided.[69]
Some have clinics, while others operate from their homes. Some community
midwives often assist the antenatal care clinics to which they are linked.[70]
The government provides community midwives with basic reproductive health
commodities such as oral and injectable contraceptives, condoms, gloves,
needles, and syringes.[71]
The Community Midwifery Approach is linked to the Community Strategy, and the
midwives work closely with community health workers and community health
extension workers.

The CMA is also intended to address the problem of traditional
birth attendants (TBAs). According to the 2008-09 Kenya Demographic and Health
Survey, TBAs attend 28 percent of all births in Kenya, the same number of
births as those assisted by nurses and midwives.[72]
In some areas in Kenya, TBAs attend to more deliveries than skilled
professionals. In Western and North Eastern provinces, for example, TBAs attend
45 percent and 64 percent of deliveries respectively.[73]
The reliance on TBAs over skilled attendants contributes to the occurrence of
obstetric fistula and maternal deaths, since they are not qualified to handle
obstructed labor or other complications during delivery.[74]
We spoke to 14 women and girls who were kept in labor for more than one day by
TBAs without being referred to a health facility and who developed fistula as a
result.

The Community Midwifery Approach and the Community Strategy are
intended to help incorporate TBAs into the wider health system in social
support roles, and thus to increase skilled attendance at births.[75]
This can prevent cases of fistula occurring.[76]
Two major challenges concern expansion to cover the whole country and sustainability
of the CMA, particularly payment of the midwives. Many women have very limited
funds to pay the midwives. If women are unable to meet the costs, then
community midwives are unable to replenish their supplies or continue to be
motivated to provide services.[77]

II.Impact
on the Lives of Women and Girls in Kenya

Profile of Kwamboka W., Kisii, November 11, 2009.

“I
got pregnant when I was 13 years old. I was in form one, and was forced to
drop out of school. When I started labor, my mum and my aunt immediately took
me to a private clinic near home. We arrived at about 6 p.m. The doctor
checked me and told me I was doing well and should deliver by 2 p.m. the
following day, but I did not. At 6 a.m. the following day I felt the urge to
push and I started pushing. At about 11 a.m. he said the baby was coming out
because he could see hair. I continued pushing, but the baby did not come
out. An hour later, my mum insisted that I go to hospital. She took me to
Ogembo hospital. It took us one hour to get there. At Ogembo the nurse
checked me and said the baby was dead and referred me to Kisii General
[Hospital]. We arrived there at 6 p.m. The doctor examined me and said the
baby was dead, and I should be taken to theatre for surgery to remove the
baby.”

“I realized
later while I was at the hospital that I could not control urine. I stayed in
hospital for two months but I did not heal. Back home, my parents collected
money from friends and we went to a doctor at Kisii General. The doctor told
me to look for KES 10,000 (US$130) for treatment. My parents did not have the
money, and people refused to help again. My parents lost hope. So I continued
to pray and just stayed at home. I have had this problem for seven years.
When I went home, I was so traumatized. I had never heard of this thing
[fistula] before. I thought it was only me with it. I thought I should kill
myself. You can’t walk with people. They laugh at you. You can’t
travel, you are constantly in pain. It is so uncomfortable when you sleep.
You go near people and they say urine smells and they are looking directly at
you and talking in low tones; it hurt so much I thought I should die. You
can’t work because you are in pain; you are always wet and washing
clothes. Your work is just washing pieces of rugs. It is difficult to walk.
You feel like your thighs are on fire. You cannot eat comfortably because you
fear the urine will be too much. I cannot get into a relationship with a man
because I feel embarrassed because I have so much urine coming out. My mother
tells me, ‘you can’t get married; how can you go to
someone’s home when you are like this? They will despise you.’ I
pity myself so much. My biggest fear is that I may never get a child. I look
at my age-mates who are married with children and I feel so worthless.”

Physical and Psychological Consequences

Without surgical repair, the physical consequences of
fistula are severe, and can include a fetid odor, frequent pelvic or urinary
infections, painful genital ulcerations, burning of thighs from the constant
wetness, infertility, nerve damage to the legs, and sometimes early mortality.
Many women interviewed by Human Rights Watch complained of difficulty walking
because the skin on their thighs stung so intensely. Many women suffering from
obstetric fistula limit their intake of water and food because they do not want
to leak. This can lead to dehydration and malnutrition.[78]
The majority of women and girls we interviewed who were married or in sexual
relationships complained of pain and discomfort during sex.

Fistula has a huge psychological
impact on women and girls, sometimes leading to depression and suicide. Most
women we interviewed described feelings of hopelessness, self-hatred, guilt,
and sadness, especially because they are stigmatized and think their condition
is untreatable. One woman told us, “You are always sad because every time
you are washing clothes, you stain everything and you smell.”[79]
Amolo A. described how hopeless she felt before she had successful fistula
surgery in 2007: “I was raped, the baby was dead, I was leaking urine and
I couldn’t be treated. I felt so hopeless. My life was just useless. I
was only 19. My age mates were getting married, and moving on with their lives
and I was an outcast…. I was just a burden to everyone.”[80]

Social Consequences

Women and girls living with fistula are often ostracized
largely because of the foul odor they produce; almost all women and girls we
interviewed said they have experienced stigma due to their odor. Nyasuguta J.
told us, “My cousin is so stigmatized. They say ‘she is just
feces’ and that she should not go near visitors. Her brothers disowned
her. When they see her approaching they say ‘the one with feces has
returned.’”[81]
Another woman told us, “I confided in a friend once.… She insulted
me and ridiculed me.… She called me a mobile pit latrine.”[82]
Awino D. said, “People laugh at me saying I am urinating everywhere. They
even sang about me in a circumcision song saying ‘someone’s wife
urinates on the mattress.’ I asked my husband ‘how come your
friends are ridiculing me?’”[83]

Fistula is more stigmatized when, due to misinformation, it
is linked to other taboo conditions such as HIV/AIDS, abortion, and
infertility. Wangui K. told us, “People … say ‘she has been
aborting. Why can’t the husband chase her and marry another woman who can
give birth?’”[84]
Muthoni M., who is living with HIV and fistula, was abused by her family and
abandoned by her husband. She said:

When I went home, he saw my condition and left home. He
said it was my problem…. The mother wants him to marry another woman. I
am HIV positive. That’s why they despise me more.... I don’t know
what I will do when I go back home because I can’t work. I think I will
go back to my parents.... I was so mistreated I thought of killing myself. You
know this is a bad combination. They say even if I go to Nairobi I won’t
get better, I will die.[85]

Fistula survivors are also thought by some to be bewitched
or cursed, or may be accused of being promiscuous. Women and girls with fistula
are often abused, beaten, abandoned, and divorced by their husbands or are
isolated in their homes or shacks outside their homes. Rose Odeny, a nurse at
Migori District Hospital who works with community midwives in the district told
us, “Most women [with fistula] in Migori have been sent away from their
[marital] homes. I find most of them at their parental home. Even when they are
not sent away, the way they are treated makes them to pack and leave.”[86]
One woman said her husband beats her because he thinks she is lazy: “He
says … ‘fellow women are doing business but you are just sitting at
home.’”[87]
Awino D., who had just left her abusive husband before our interview, told us,

I stayed with my husband for about five years. There was so
much violence…. At home they insulted me that I am filling the toilet and
yet I have no child. They said that their son should marry another wife because
I am wasting his time…. There was a day he told me as he was beating me,
‘leave so that I can marry again.’ I left him in August 2009. He
beat me and I decided I had had enough and went back to my parents.[88]

Fistula often leads to loss of social belonging and
association. Many women and girls with fistula lead isolated lives, confining
themselves to their homes due to the stigma and shame attached to the illness.
A large number of those we interviewed did not go to church, the market, or
other social places. For example, Fatuma H. told us, “When you have this
problem you have a lot of worries. You don’t have a lot of comfort. You
can’t mix freely with other people. You feel guilty to mix with them. You
fear the thing [the rugs used to keep dry] will come out and embarrass you. You
can’t even go to church.”[89]
About five of the girls we interviewed said they would have wanted to return to
school after giving birth, but fistula made it impossible.

Economic Consequences

Fistula places a huge financial burden on poor families.
Frequent infections mean women and girls regularly need medical attention. Women
also told us that they need petroleum jelly to soothe the burning on their
thighs because they cannot afford regular medical care for this. Almost all the
women we spoke to said they could not afford to buy sanitary pads and instead
used rugs and pieces of old clothes to control the constant trickle of urine
and feces. It is also expensive to keep the rugs clean. Women told us that they
needed to bathe, change, and wash their rugs and clothes several times a day to
stay clean. For this, they need extra supply of soap, which is expensive. Gesare
J. told us, “It is expensive to have this problem. At night, I have to
keep a basin with Omo [washing powder] and water so that I use it and then pour
it in the morning, otherwise the whole house will smell. It is expensive to
keep yourself clean, you need to bathe and wash clothes all the time. You need
Vaseline [petroleum jelly] to apply to the thighs. It is really hard.”[90]

Women and girls with fistula may also lose property when
they are divorced or chased away by their husbands. All the women and girls we
interviewed who had left or been chased away by their husbands told us they
left with no share of the family property. Nyakiriro C. told us, “When I
got the problem, my husband told me to go back to my mother.… I left with
no property. He sold the land and the livestock after I left.”[91]
Another one told us, “I left home with nothing. We did not have much but
I did not get my share of [the property].”[92]

Fistula decreases women’s and girls’ abilities
to farm or do other economic activities. Although some women told us that they
were able to work on their farms despite the pain and discomfort they suffered,
others said they were not able to. Some lose jobs or are denied work when
employers discover that they have fistula. For example, Nyaboke H. told us,

My husband chased me away when I got this problem
[fistula]. He used to beat me a lot. When I went back to my parents, my
sister-in-law also became abusive saying she did not want a dirty smelly person
in the home. I left, went to a nearby town, and rented a house. I started doing
casual jobs like washing clothes and fetching water, but whenever it was
discovered that I had a problem of [controlling] urine, I was chased away.
Before long, everybody knew about my problem and I stopped getting work. I used
to lock myself in the house and cry the whole night, and sleep hungry.[93]

Other women quit their jobs out of shame. Beatrice N. told
us, “I felt bad. I felt like keeping to myself. I stopped going to
church. I stopped my cleaning job at Maseno University and stayed at home
because I felt ashamed.”[94]
Because of the shame and guilt women feel as a result of having fistula, they
are reluctant to look for work or ask for financial support from their husbands
and other family members.

III. Kenya’s Obligations under International,
Regional, and National Law

The Kenyan government has obligations under international,
regional, and national law to protect the human rights of women and girls,
including rights relating to their reproductive and maternal health.

Violations of human rights protections and standards
guaranteed by national, regional, and international laws contribute to the
occurrence of fistula and impede its treatment and elimination. The rights that
Human Rights Watch found to have been routinely violated among women and girls
suffering from fistula include the right to the highest attainable standard of
health, the right to equality and non-discrimination, the right to information,
and the right to a remedy.

Kenya is a state party to several international and regional
human rights treaties that establish a right to the highest attainable standard
of health and provide important protections for the rights of women and girls,
including reproductive and maternal health. At the international level, Kenya
has ratified the International Covenant on Civil and Political Rights (ICCPR),[95]
the International Covenant on Economic, Social and Cultural Rights (ICESCR),[96]
the Convention on the Elimination of All Forms of Discrimination against Women
(CEDAW),[97] Convention
on the Rights of the Child (CRC),[98] and the
Convention on the Rights of Persons with Disabilities (CRPD).[99]

At the regional level, Kenya has ratified the African
Charter on Human and Peoples’ Rights (African Charter),[100]
and the African Charter on the Rights and Welfare of the Child,[101]
and signed but not ratified the Protocol to the African Charter on Human and
Peoples' Rights on the Rights of Women in Africa (the Maputo Protocol).[102]

Kenyan law has important protections for the realization of
the reproductive and maternal health rights of women and girls. The Kenya
Constitution prohibits discrimination on the grounds of sex, residence, or
place of origin.[103]
Provisions in the Children’s Act include the right to non-discrimination
and to health. On health, it states that “Every child shall have a right
to health and medical care the provision of which shall be the responsibility
of the parents and the Government.”[104]
The Act further states that “The Government shall take steps to the
maximum of its available resources with a view to achieving progressively the
full realization of the rights of the child.”[105]

The Right to Health

Health is a fundamental human right enshrined in numerous
international human rights instruments, including the Universal Declaration of Human
Rights, the ICESCR, the African Charter, the CRC, and CEDAW. The ICESCR
specifies that everyone has a right "to the enjoyment of the highest
attainable standard of physical and mental health."[106]

Because states have different levels of resources, international
law does not mandate the kind of health care to be provided, beyond certain
minimum standards. The ICESCR provides that the rights guaranteed by it,
including the right to health, are subject to "progressive realization,”
meaning that a state should "take steps to the maximum of its available
resources" to achieve the full realization of the right to health. States
are obliged to endeavor to create conditions that would assure access to all
medical services and medical attention in the event of sickness.[107]

The Committee on Economic, Social and Cultural Rights, which
oversees implementation of the ICESCR by states parties, has provided examples
of what may constitute a failure of a government to fulfill its obligations
with respect to the right to health. The examples include failing to adopt or
implement a national health policy designed to ensure the right to health for
everyone, insufficient expenditure or misallocation of available public
resources which lead to the non-enjoyment of the right to health by individuals
or groups, particularly the vulnerable or marginalized, and the failure to
reduce infant and maternal mortality rates.[108]

The Committee has also set out what it considers to be the
essential elements of the right to health (availability, accessibility,
acceptability and quality), as well as minimum “core obligations”
of governments. The basic elements of this right and the minimum core
obligations are described in detail in General Comment No. 14 of the Committee
on Economic, Social and Cultural Rights. That General Comment emphasizes the
minimum core obligations of a government in terms of health care, which
include, for example, “the right of access to health facilities, goods
and services on a non-discriminatory basis, especially for vulnerable or
marginalized groups” and “equitable distribution of all health
facilities, goods, and services.”[109]
On economic access, the Committee states:

Health facilities, goods and services must be affordable
for all. Payment for health-care services, as well as services related to the
underlying determinants of health, has to be based on the principle of equity,
ensuring that these services, whether privately or publicly provided, are
affordable for all, including socially disadvantaged groups. Equity demands
that poorer households should not be disproportionately burdened with health
expenses as compared to richer households.[110]

The ICESCR stipulates that states parties must take steps to
reduce the stillbirth rate and infant mortality and to provide for the healthy
development of the child.[111]
The Committee on Economic, Social and Cultural Rights states that ensuring “reproductive,
maternal (pre-natal as well as post-natal) and child health care” is of
comparable priority to the core obligations.[112]
Lowering of maternal mortality is identified as a “major goal” for
governments.[113]

Building upon the provisions of the ICESCR, the Convention
on the Rights of the Child also addresses the obligations of states parties in
respect of the right to health of children, and states that governments must
act in the areas of child health and pre- and post-natal health care, in particular
primary health care.[114]
Similarly, CEDAW protects the right of women to access health care without
discrimination and to get “appropriate services in connection with
pregnancy, confinement and the post-natal period, granting free services where
necessary, as well as adequate nutrition during pregnancy and lactation.”[115]
The CEDAW Committee, a body of experts that monitors implementation of the convention,
notes that high maternal mortality and morbidity “provide an important
indication for States parties of possible breaches of their duties to ensure
women’s access to health care.”[116]

The Right to Information

Information is a key aspect of the right to health and is
critical to women’s reproductive health. The Committee on Economic,
Social and Cultural Rights notes that the obligation to fulfill the right to
health requires the state to promote health by undertaking research,
disseminating information on harmful traditional practices and availability of
services, training health providers to respond to the specific needs of
vulnerable or marginalized groups, and supporting people to make informed
choices about their health.[117]
The CEDAW Committee has called on states parties to take steps under the right
to health, in particular to “prioritize the prevention of unwanted
pregnancy through family planning and sex education and reduce maternal
mortality rates through safe motherhood services and prenatal assistance.”[118]
The Convention on the Rights of Persons with Disabilities requires states to
provide “access to age-appropriate information, reproductive and family
planning education.”[119]

The CRC provides for the child’s right to “seek,
receive and impart information of all kinds”[120]
and requires states to ensure access to child-friendly information about
preventive and health-promoting behavior, and to abolish harmful traditional
practices such as early marriage and female genital mutilation.[121]
The African Charter recognizes that every individual has “the right to
receive information” and “the right to education.”[122]
The Maputo Protocol specifically includes “the right to have family
planning education” and further obligates governments to “provide
adequate, affordable and accessible health services, including information,
education and communication program to women especially those in rural
areas.”[123]
The Committee on Economic, Social and Cultural Rights recognized that the right
to health includes the right of access to information and health-related
education.[124]
The particular needs of women in relation to access to health-related
information have also been highlighted by the CEDAW Committee and the UN
Special Rapporteur on Health, who has stated that one of the factors that make
women more vulnerable to ill-health is a lack of access to information.[125]

Right to Equality and
Non-Discrimination

Human rights law and standards guarantee women the right to
equality and non-discrimination. CEDAW is the treaty that sets out most
comprehensively the areas in which governments should be working to eliminate
discrimination against women, and in article 12 specifically addresses the area
of health. Under CEDAW states parties are required to “eliminate
discrimination against women in the field of health care in order to ensure, on
a basis of equality of men and women, access to health care services, including
those related to reproductive health.”[126]
The Maputo Protocol also calls upon states to reform laws and practices that
discriminate against women, while the Convention on the Rights of the Child
guarantees children the right to be free from discrimination.[127]
Under the principle of non-discrimination, adolescents should enjoy the same
rights to reproductive health services as adults, as consistent with their
evolving capacities.

Because only women require health care services for
pregnancy and childbirth, states are under obligation to take special measures
to make such services available and accessible, while ensuring that they are
acceptable and of adequate quality. Failure to make efforts to do so is a form
of discrimination. Certain groups of women face not only gender discrimination,
but experience discrimination due to their economic status, geographic
location, and age. Under article 14 of the CEDAW, governments must make special
efforts to ensure that women in rural communities are not disadvantaged,
particularly regarding “access to adequate health care facilities,
including information, counseling and services in family planning.”[128]

The Right to a Remedy

Regional and international treaties establish the basic
right of individuals to an effective remedy when their human rights have been
violated. The Committee on Economic, Social and Cultural Rights has recognized
the rights of victims of violations of the right to health to access judicial
or other remedies and adequate reparation in “the form of restitution,
compensation, satisfaction or guarantees of non-repetition.”[129]
Likewise, the Maputo Protocol specifically recognizes women’s right to
redress, requiring states to “provide for appropriate remedies to any
woman whose rights … have been violated … [and] ensure that such
remedies are determined by competent judicial, administrative or legislative
authorities, or by any other competent authority provided for by law.”[130]
The Human Rights Committee has emphasized that states must ensure
“accessible and effective remedies” for human rights violations and
to take into account “the special vulnerability of certain categories of
person,” and further noted that “a failure by a State Party to
investigate allegations of violations could in and of itself give rise to a
separate breach of the Covenant (ICCPR).”[131]

The right to a remedy in the context of the right to health
is closely linked to accountability, which is a key element in ensuring the
right to health and in the enjoyment of all human rights. The UN Special
Rapporteur on the right to health has stated that “without
accountability, human rights can become no more than window-dressing.”[132]
Accountability has been called the “raison d’être of a
rights-based approach.”[133]
It has two main components: redressing past grievances and correcting systemic
failures. Accountability is not about blame and punishment, but it is a process
that helps to identify what works so it can be repeated and what does not so it
can be revised.[134]
Where mistakes have been made, accountability requires redress.[135]
It is also concerned with ensuring that health systems are improving, and the
right to the highest attainable standard of health is being progressively
realized for all, including disadvantaged individuals, communities, and
populations.[136]

IV. Access to Health Information

Access to health information is a necessary part of
women’s and girls’ ability to make informed choices and to access
health services needed to ensure healthy pregnancy and delivery and treatment
for related complications such as obstetric fistula.

Various information gaps noted in this report—concerning
sexuality education, family planning, cost of care, government policies on fee exemptions
and waivers, what fistula is, and availability of fistula repair services—show
major shortcomings in the Kenyan government’s obligations to ensure that
the public has adequate health information. The government is aware of such
gaps but has not taken deliberate and targeted measures to substantially reduce
them.

The right to access health-related information translates
into both negative and positive obligations on the part of the state. On the one
hand, the state is obligated to refrain from limiting access to information and
from providing erroneous information. On the other hand, it must ensure access
to full and accurate information. Paragraph 34 of General Comment No. 14 of the
Committee on Economic, Social and Cultural Rights calls upon states to “refrain
from limiting access to contraceptives and other means of maintaining sexual
and reproductive health, from censoring, withholding or intentionally
misrepresenting health-related information, including sexual education and
information.”

Sexuality Education

The risk of obstetric fistula often begins when young girls
get pregnant or marry early, before their bodies are able to safely sustain a
pregnancy. One of the factors leading to early pregnancy and childbearing is
the lack of accurate reproductive health knowledge. We spoke to some girls who
displayed a lack of basic knowledge on sexuality while others told us that they
did not have this knowledge before becoming pregnant. Ten of the girls aged 18
years and below whom we interviewed told us they got pregnant from their first
sexual encounter. Seven of them said they had unprotected sex but thought they
would not get pregnant because it was their first time, two said it was because
they had irregular menstrual periods, and the other because her boyfriend told
her she would not fall pregnant. For example, 17-year-old Mueni M. who became
pregnant in 2008 while in primary school told us, “I did not know I would
get pregnant because it was the first time. I did not know anything about
condoms.”[137] She
also told us that they had not received any sexuality education in school.[138]
Kemunto S. also became pregnant while in primary school. She said, “I got
pregnant when I was 16 years old. I was in standard seven and thought because
my periods did not come every month I would not fall pregnant. I did not know
anything about contraceptives although I had heard people talk about
condoms.”[139]

Unease surrounds the topic of sexuality education in Kenya,
with some parents and religious leaders opposing the provision of such
education because, they say, it would lead to promiscuity.[140]
For example, a primary school teacher told Human Rights Watch, “Parents
don’t want it [sexuality education] sometimes. They say children are
taught how to be promiscuous. Another teacher was telling me the other day that
parents in his school say we are teaching their children how to have
sex.”[141]
Another teacher, Stella Kinaki said, “We have parents who say what we are
teaching [sexuality education] is spoiling their children. Sometimes we go for
meetings and some teachers are also not comfortable with some of the things we
are supposed to teach.”[142]
Another one told us, “It is not just pupils who need sexuality education.
Parents also need to be told why it is important.”[143]

The government has made efforts to introduce life skills
training, which includes sexuality education, in schools. In January 2008, the
government asked upper primary and secondaryschools
to teach life skills and called for the provision of adolescent/youth-friendly
reproductive health services.[144]
In 2009, the Ministry of Public Health and Sanitation and the Ministry of
Education launched a National School Health Policy and implementation
guidelines that address sexuality issues.[145]
Experts say there are gaps in implementing this policy.[146]
Teachers interviewed by Human Rights Watch told us that lack of time, because
sexuality education is not part of the school syllabus and therefore not a
priority subject, is the main hindrance to it being taught in schools.[147]
A headmaster at a primary school told us, “We appreciate that this is an
important issue for children to learn, but unless we make it part of the
syllabus, time will always be a barrier.”[148]

Family Planning
Information

Family planning education, information, and services are
critical to women’s wellbeing and to their reproductive and maternal
health. Adequate information about the advantages of family planning and
contraception methods, as well as access to such services, is important for
reducing maternal deaths and morbidities such as obstetric fistula because it
helps women to have planned pregnancies. According to the 2008-09 Kenya
Demographic Health Survey, 43 percent of most recent births were not planned,
underscoring the need for family planning education and services.[149]

Our interviews show that access to accurate and
comprehensive family planning information for some of the rural women and girls
is a challenge. About half of the women we spoke to said they had no knowledge
of family planning and contraception before they got pregnant and an equal
number told us that they had learned more about family planning during
antenatal care, and none of the women said they received family planning
information from a community health worker.Misinformation is a
problem as well as lack of information. Seventeen-year-old Monica J. told us,
“My boyfriend told me the withdrawal method was best for us because we
were not married. I don’t know about any other method.”[150]

Our research shows that there is need to take deliberate
steps to educate rural, young, and illiterate women about the importance of
family planning and the available methods. The government is aware of the
information deficit among poor, rural, and uneducated women.[151]

The Community Strategy provides an opportunity to reach rural
women with family planning information. One of the activities in the Community
Strategy is provision of family planning information and services. Community
health and extension workers are required to create awareness on the importance
of family planning and services available, but none of the women and girls we
interviewed had received such information from these workers. Current available
data from the 2008-09 KDHS indicates that a mere 5 percent of women who are not
using any family planning method are being reached by field workers to discuss
family planning issues, and only 9 percent who visited health facilities in the
12 months before the survey discussed issues of family planning with the health
facility staff. This implies that many opportunities are lost to educate
potential users on the benefits of family planning.[152]

Fistula repair camps also present an opportunity to talk to
women and girls about family planning, but this does not always happen. Three nurses,
out of the five we interviewed working in fistula wards, told us that they do
not talk to women about family planning. For example, one of the nurses, a
trainer on post-operative care for fistula patients, said, “We do not
give them [women and girls] any information on family planning because we do
not allow for sexual activity before six months; we tell them to abstain. Also,
many do not have children.”[153]
A nurse at Jamaa Hospital told us that their policy—they are a Catholic
mission hospital—does not allow them to talk to women about family
planning.[154]
This assertion was confirmed by the hospital administrator.[155]

Under the focused antenatal care program, women and girls
should be given post-partum family planning information,[156]
which is important for making decisions about the healthy spacing of
pregnancies, the mother’s risk of unintended pregnancy after birth, and
specific methods of post-partum family planning such as lactational amenorrhea.
A study by Population Council found that providers failed to provide this
information consistently.[157]
In addition, post-natal care attendance is very low in Kenya, further limiting
opportunities for provision of family planning information. The current
Demographic and Health Survey shows that 53 percent of women did not receive
postnatal care for their most recent birth, particularly poor, illiterate, and
rural women.[158]

Information on the Need
for Facility Deliveries

As noted earlier, a key government priority in improving
maternal health is increasing access to skilled attendance during pregnancy,
delivery, and after delivery. Women and girls should be told about the
importance of facility delivery during antenatal care visits and in communities
through community health and extension workers, but this is not always the
case. Although only ten women out of the 40 we interviewed who said they
attended antenatal care said they were not given this information, there is
need to ensure that all women understand the importance of delivering in a
medical facility.

Gaps also exist in giving women information about potential
complications during childbirth, as discussed in more detail below. It is
important that at antenatal care women are told about possible complications
that could arise, and that these can happen with any pregnancy. We spoke to four
women who said they delivered at home because they had had prior uncomplicated
births at home. One told us, “I had four deliveries at home and they were
very easy and I normally deliver after a very short while after experiencing
labor. I delivered with assistance from my husband's grandmother but this time
I don’t know what went wrong.”[159]

Over half of all births in Kenya are categorized as high
risk births, that is, births to women with three births or more, to those older
than 34 years, or to those younger than 18 years.[160]
These statistics underscore the need for the government to scale up information
to women and communities on the value of women giving birth in health
facilities. Additionally, it is important for the government to monitor the
kind of information that women are given during antenatal care. Human Rights
Watch interviews with nine nurses, three from dispensaries and six from
hospitals, revealed that there were no oversight mechanisms at their facilities
to ensure that health providers are giving women the required information
during antenatal and postnatal visits.

Information on What
Fistula Is and Treatment Availability

Almost all the women and girls we interviewed had never
heard about fistula before they developed it, and many were surprised to come
to the hospital and meet so many women seeking fistula treatment.[161]
They had thought they were the only ones.

Misinformation about fistula abounds, contributing to delays
in seeking treatment. Some women thought that incontinence was normal after
delivery,[162] that
they got fistula after Cesarean sections,[163] or
that the bladder cannot be repaired.[164] An HIV
positive woman told us people in her community say she got fistula because she
is HIV positive and she believes that because HIV cannot be cured, fistula too
cannot.[165]

Some TBAs and religious leaders perpetuate these myths by
giving wrong information to women who seek their help. Nyakundi B. lived with
fistula for four years because when she told her mother about her condition,

My mum took me to a traditional healer who told her that
the doctors left cotton inside me and that’s why I had the problem. They
told her they would pray for me and I should go to their church. I went many
times and they prayed but nothing happened so I stopped. I just stayed at home
until I heard about the camp on radio.[166]

Over half of the women and girls we interviewed informed us
that no one explained fistula in health facilities where they delivered or when
they sought fistula treatment.[167] Six of
the nurses we interviewed said they did not talk to women about fistula or
incontinence during antenatal or postnatal care visits.[168]
All of them said they lacked the time to talk to women about a range of
important issues because of capacity. A nurse at Kisii General Hospital told
us,

It is true that we do not talk about fistula to patients
and that it is not integrated in the health talks. It is a big gap. But the
hospital is busy and staffing is limited. Maybe you are one nurse with many
people waiting. You feel like you want to give the most basic information. Work
is always overwhelming. There is no time to give them all the information they
should get at focused antenatal care and time for them to ask questions.[169]

A number of the nurses and doctors we spoke to observed that
some health providers also lack the necessary information about fistula to
educate women.[170]

Lack of information on fistula among some healthcare
providers hinders appropriate and timely referrals and adds to women’s
and girls’ suffering. We spoke to women who said they were asked to keep
going to hospital without any explanation of what the problem was and what
treatment they would be getting or if they would get better. Mueni M.’s
case is an example. She told us “I went home and realized water [urine]
was coming out. I went back to Wote and asked them ‘what is wrong’
and they just said I be going to clinic. I went back three times and saw it
wasn’t helping and so I stopped going.”[171]
Another woman told us,

I developed the problem when I was in hospital. They put a
tube in me but it did not help. They said I go home and gave me a return date.
I went home and the problem got worse. I returned to the hospital but they said
I wait for the appointment day. I went back home and returned on the
appointment date. They checked and gave me medicine and told me to come after
one month. The tablets didn’t help but I came back after one month. They
gave me another day to come back. This continued three times and I got tired
and I stopped coming.[172]

The situation can be particularly bad when health providers
fail to give correct information. Kemunto S. got fistula when she was 16 years
old. The doctor at Kisii General Hospital (a level 4 facility then) where she
delivered told her, “[G]o home … eat and get fat. [T]he problem
will end.” She told us, “I stayed at home for one month but the
problem was getting worse. I came back and they said just go home and eat. They
told me to eat soft food and vegetables because these would help in natural
repair. I went home, ate them but nothing happened; the urine and stool were
coming out.[173]
Kemunto S. was highly stigmatized by her family and community, and developed
mental problems. In 2002, after living with fistula for 10 years and enduring
physical violence from her husband, she convinced her husband that they should
seek treatment. However, he got frustrated with the back and forth journeys to
the hospital, told her to stop treatment, and eventually chased her away. She
narrated her story to Human Rights Watch:

In 2002 my husband looked for money and we went back to
Kisii General. The doctor examined me and told me to come back after one month.
I came back but they said the doctor was not around. They told me to take two
weeks and return. I returned after two weeks and they said I needed to be
examined in the lab. The lab said I go to Dr. Kasioki [not his real name] to
get the results. I went to him. He didn’t tell me anything. He said go
and come another day. My husband got annoyed, he was frustrated and asked me to
stop going to hospital but I convinced him that we try once more. We returned
after two weeks. I went to Dr Kasioki. He just looked at me and said he
couldn’t help me. He told my husband I couldn’t become pregnant. My
husband said I had miscarried but the doctor insisted I can’t conceive or
be cured. My husband got annoyed. He said to me, when we go home, I want you to
take your clothes and leave and go back to your parents because you cannot fall
pregnant.[174]

Many women and girls do not seek fistula surgery because
they do not know that these services are available. There is little or no
mobilization done except for announcements about free repair camps. Dr. Mitei,
a fistula surgeon at Kisumu Provincial General Hospital told us,
“Patients don’t just come; they come during camps when there is
good mobilization unless they are referred by other patients, which is very
rare.”[175]
The Freedom from Fistula Foundation is the only organization doing routine
mobilization, but even so, they say they are limited by capacity. The
organization has hotlines that women can call for referral to Jamaa Mission Hospital.[176]

In 2004, the Division of Reproductive Health in what was the
Ministry of Health and UNFPA conducted a fistula needs assessment in Kenya that showed lack of awareness about fistula in communities as a barrier to its
prevention and treatment. Seven years later, the problem persists, and the
government has done little to address this barrier by providing accurate
information about the causes of fistula in communities.

Information about fistula and the availability of treatment
is mainly done before fistula camps, which involve mobilization, screening of
women for obstetric fistula, and repair surgery for those affected. Often, the
information is targeted towards communities in the region where the camps will
be held. This leaves out regions where fistula camps have never been held. The
government needs to conduct a country-wide information campaign about fistula
through the mass media, and through other avenues such as churches, community
health workers, and provincial administrators who work with rural communities.

The government has a key role to play in ensuring women have
access to accurate and up to date information about fistula to ensure that it
is meeting its obligations to correct persistent myths and misinformation about
fistula in the communities. The Kenya government should take measures to ensure
that health providers have knowledge about fistula and that they give this information
to women and girls during antenatal and postnatal care visits. It can do this
by integrating information about fistula into in-service training for health
providers.

V.Availability and Accessibility of Services

An equitable, well-resourced, accessible (physically and
financially) and integrated health system is widely accepted as being a vital
context for guaranteeing women’s access to the interventions that can
prevent or treat the causes of maternal deaths and injuries such as obstetric fistula.[177]

Kenya has taken many positive steps to advance women’s
and girls’ maternal and reproductive health. These initiatives include eliminating
charges for public family planning services, antenatal and postnatal care, and
prevention of mother-to-child HIV transmission. The government has also
eliminated charges for delivery in dispensaries and health centers to encourage
women to deliver in medical facilities with a skilled birth attendant. In
addition, by introducing a system of full or partial fee waiver for access to
government hospitals, the government has taken steps to increase access to
health care for indigent patients. However, slow and sometimes absent progress
in certain key areas calls into question whether Kenya is living up to its
obligation with respect to the right to health. Many of the problems affecting
the health sector in Kenya have persisted for many years. They include shortage
of medical staff, mal-distribution of available staff and health facilities to
the disadvantage of rural and poor regions, frequent shortages of supplies
including family planning supplies, and failure to ensure health services are accessible
to the poor.

Family Planning

Family planning is recognized by experts as key in reducing
maternal mortality, improving women’s general wellbeing and accelerating
progress toward achieving the Millennium Development Goals. For example, family
planning can reduce the number of times a woman becomes pregnant. Generally
speaking, women who have had three births or more face greater risks in
pregnancy. Family planning reduces the number of unintended and unwanted
pregnancies, which are far more likely to end in induced abortions, and are far
less likely to receive adequate prenatal care than planned pregnancies. In
addition, family planning can be targeted to reduce the number of pregnancies
to women in groups at increased risk of maternal death, such as women who are
too young or older, and women who have had more than five previous births.[178]

Women and girls in Kenya face a number of obstacles in
accessing family planning, one being lack of sufficient facilities offering a
wide variety of family planning methods. Current available data indicates that
“the proportion of health facilities offering any temporary modern
methods of family planning declined to 75 percent in 2004 from 88 percent in
1999.”[179]

Another challenge is contraceptive stocks. The family
planning findings of the Kenya Service Provision Assessment Survey found that
as of 2004 (more recent data is not available), “19 percent [of
facilities] providing combined oral contraceptives and 18 percent of facilities
providing progestin-only injectables reported a stock out sometime in the six
months before the survey.”[180]

In August 2009, media reports revealed that contraceptives
were largely out of stock across the country. For example, Muraguri Muchira,
the director of programs at Family Health Options Kenya, one of the largest
providers of family planning in the country, was quoted saying that
injectables, one the most common methods of contraception in Kenya, were not
readily available then: “We don’t have enough of them in the
government supplies or even the Non Governmental Organisations. In our (Family
Health Options) case, we are sometimes forced to buy from the private sector
which is very expensive and we can’t afford to buy enough quantities to
meet the demands.”[181]
According to Muchira, “The biggest challenge we have as a country is the
sourcing of contraceptives. Kenya depends highly on development partners and
each one of them brings their supplies in their own different channels. So
it’s very difficult to know how much is being brought in the country at
any one time. And as far as I know nobody has come up with a solution.”[182]

In Kenya, as elsewhere in sub-Saharan Africa, the past
decade has seen a weakening prioritization of contraceptive programs,
undermining access to services.[183] An
analysis of the 2009/2010 Kenyan budget by Deutsche Gesellschaft für
Technische Zusammenarbeit (German Technical Cooperation, GTZ) indicated that,
“Against the general trend, the allocation for Family Planning, Maternal
and Child Health is declining by 15%. Only 1.8% of the overall government
expenditures on health are spent on this issue.… This is clearly
contradictive to policy objectives.”[184]

Human Resource
Constraints

The availability, quality, comprehensiveness, and
utilization of health services, including maternity services, offered at a
health facility depend, in large part, on the number of health workers at that
facility. The Kenyan health sector suffers from longstanding human resource
shortages, especially in rural areas.[185]
According to the Human Resource for Health Strategic Plan, “there are
overall staff shortages (47,247 staff against an estimated minimum requirement
of about 72,234). Shortfalls are heavily concentrated in parts of Coast, North
Eastern Rift Valley and Nyanza Provinces, areas that have the lowest health
indicators.”[186]
The two health ministries note that “government personnel remain heavily
skewed in favour of hospitals and the better-off districts.”[187]
Hospitals and high-level facilities have more qualified staff.[188]

In 2005, it was estimated that “[d]ispensaries
have a median of one enrolled midwife while health centers have a median of one
enrolled nurse and one enrolled midwife. Hospitals have a median of three
doctors.”[189]
Two of the dispensaries we visited in Machakos and Kisumu had only one nurse
attending to all categories of patients. When we arrived at the dispensary in
Machakos, there was a long queue of men and women with children waiting to be
attended to by the one nurse, who informed us that she was late because she had
to purchase some supplies. At the Machakos General Hospital, a nurse in the
gynecology ward had to ask a nurse from another ward to assist in giving
patients medicine because she was alone in ward of about forty patients, and
she was not able to attend to all of them in a timely manner.

Another challenge is that health facilities
serve very large populations: “The median population in a hospital
catchment area is more than 100,000, while dispensaries, which have limited
staff, serve a catchment population of around 8,000.”[190]Many of the doctors, nurses and experts we interviewed
reiterated this concern. There are also problems with retaining staff in
hard-to-reach and rural areas.

In order to make substantial progress in reducing maternal
mortality and morbidity, the Kenyan government should be developing and
implementing a plan that aims to ensure that there is a sufficient quantity of qualified
health workers available, whose services can be provided in a fair and
equitable distribution throughout the country.

Poor Access to
Emergency Obstetric Care

Another critical problem that women face in accessing
maternal health services, and thus avoiding fistula, is lack of adequate
facilities offering delivery and emergency services. Only about 38 percent of
facilities offer normal delivery services. Hospitals, which are usually located
in urban and peri-urban areas, offer most of these services.[191]
Facility-based 24-hour delivery services are available in 64 percent of health
centers in the country.[192]

Many women in Kenya have poor access to emergency obstetric
care that could save both their lives and prevent stillbirths in case of
complications during pregnancy or childbirth. Women with obstructed labor,
which can lead to fistula, need emergency obstetric care such as Cesarean
sections.[193]
The 2004 Kenya Service Provision Assessment Survey concluded that capacity to
manage common or serious complications of labor and delivery is weak in all
facilities, including hospitals.[194]
Less than 10 percent of medical facilities in the country were able to offer
basic emergency obstetric care as of 2004.[195] The
national coverage rate for basic emergency obstetric care was 2.7 per 500,000
population (well below the recommended level of four per 500,000 population) in
most provinces.[196]
Only six percent of medical facilities can provide comprehensive emergency
obstetric care.[197]

Poor Transport and Referral System for Women and
Girls in Labor

Transport availability and poor road infrastructure
influence the ability of pregnant women, especially those in rural areas, to
deliver in health facilities and to access emergency obstetric services.[198]
Jessica Momanyi, nursing officer in charge of reproductive health at Kisii
General Hospital, told us: “We see many cases that come here and they are
too late. They delay too much at the community level because of transport
issues.”[199]
Transport is a major problem at night. Some women told us about having to walk
long distances while in labor to get to the nearest health facility and others
said distance to facilities and lack of transport forced them to deliver under
TBAs. More than half of fistula patients
we interviewed cited transport problems.

Poor access to transport contributes to fistula

“I
began labor at 7 p.m. and I said I will go to the hospital in the morning.
However, at around 2 a.m., the pain became so severe and the baby was coming
fast. My husband tried to get a vehicle but we didn’t get one. My
mother-in-law called some old women to help me. We went to the hospital the
following morning and arrived at 9 a.m. The nurse said the baby was not
breathing. I had a stillbirth. When I went back home I realized water was just
coming out. Later I realized it was urine coming out.”

“I
started labor about 2 p.m. My mum left and came back with an old woman who
started examining me. The old woman she said the way of the baby was okay and
I would deliver well. At 3 a.m, I had not delivered and my mum told her we
should go to the hospital because I was in so much pain. However, we
couldn’t get a vehicle at 3 a.m. so we waited until morning. My mother
also realized she did not have money, and she had to borrow some from
relatives. When we got to the dispensary the following day later in the
afternoon, the nurse said we had delayed at home and the baby was dead. They
took me to hospital and removed the baby. Then I developed this problem
[fistula].”

“I
felt some pains early in the morning. I went about doing my home chores. By
evening, the pains were still mild so I went to bed. Around 1 a.m. the pain
became so severe but we had to wait till morning to go to the dispensary
because it was raining and the road was bad. We also couldn’t get a
vehicle at night.”

Lack of transport between health facilities is common, and
interferes with referrals for emergency obstetric care in higher level
facilities. Many health facilities, particularly dispensaries and health
centers, do not have ambulances.[200]
Even in cases where there are ambulances, there are other problems such as lack
of fuel. Beatrice N. started labor at 3 a.m. and quickly went to the nearest
dispensary. They told her she would deliver at noon, which did not happen. At 6
p.m. they told her mother to take her to Kisii General Hospital. She said,
“They said their car did not have fuel. We hired a car.”[201]
Other times, there is delay at the referral facility. A nurse at Rabuor
dispensary in Kisumu told us, “Sometimes you call the district hospital
and they delay. I had a woman who had serious problems and they took over four
hours to arrive.”[202]
A nurse at a district hospital remarked, “Fuel is a challenge. I have
heard the drivers say on several occasions that there is no fuel when
dispensaries call for patients. This leads to delay in women getting help.”[203]
A doctor also noted, “Unless we give attention to dispensaries and health
centers [by equipping them with ambulances], women will continue to get
fistula.”[204]

The Kenyan government is in the process of finalizing a
referral strategy that aims to improve communication and transportation between
lower level and higher level referral health facilities through purchase and
distribution of ambulances, and “To develop service providers’ capacity
to offer services and appropriately refer at each level of the healthcare
system.”[205] The
government should prioritize the completion of this policy as well its
implementation, with a focus on rural and marginalized regions. In addition,
the government should also prioritize implementation of the referral component
of the community strategy, which would empower communities and families to
prepare for obstetric emergencies.[206]

Facility and Staffing
Challenges for Fistula Repairs

Efforts to address fistula in Kenya are largely focused on
training surgeons to provide repair surgeries. In spite of ongoing efforts,
lack of trained fistula surgeons remains a major challenge to addressing
fistula in Kenya. Obstetric fistula is not a key area of gynecological
training; doctors do not come out of university as competent fistula surgeons.
Countrywide, there are about ten trained fistula surgeons and only four (one of
whom is a retired private consultant) are considered experts able to handle
complicated cases and to train others. Three of the experts are based in
Nairobi and only occasionally travel to provincial or district hospitals during
camps to assist in surgery and to train other doctors. Many people interviewed
by Human Rights Watch said there is a general lack of interest in fistula
training among doctors because the specialty brings little monetary gain.[207]

In addition, there are few hospitals equipped to handle the
surgeries. Those that exist often lack equipment and supplies necessary for
fistula repair. Availability of operating theater facilities is a common
problem. Because fistula surgery is not considered an emergency, it is not
prioritized. Dr Paul Mitei, a fistula surgeon at Kisumu Provincial General
Hospital told us, “To do this work in a public hospital is not easy
because there are many competing interests…. You may find there is no
anesthetist, no theater table. On the day you have your elective [fistula
surgery] if there are emergencies … you just put off.”[208]

Routine fistula surgery is rare. Although a number of
hospitals have the capacity to offer routine repairs, countrywide, fistula
surgery is mainly done routinely in only three facilities: Kenyatta National
Hospital (KNH) in collaboration with the Africa Medical Research Foundation
(AMREF), Moi Referral and Teaching Hospital (national level public facilities)
and at Jamaa Hospital, a mission facility. KNH and Jamaa are both based in
Nairobi, even though most women needing surgery are from rural areas, far away
from Nairobi.

Repair surgeries are done mainly through fistula camps,
which are chiefly meant to be training camps on fistula repair and management
for a mixed skill team of doctors, nurses, physiotherapists, anesthetists, and
other medical support staff.[209]
Trained surgeons (mainly gynecologists) are then supposed to begin routine fistula
surgery, but this hardly happens. However, many doctors, NGO representatives,
and government officials we spoke to acknowledged that while fistula camps are
good for training, they are not sustainable in the long run nor are they the
best way of ensuring all women and girls living with fistula get timely
treatment.[210]

One of the reasons why fistula surgeons do not offer routine
surgery includes lack of long-term mentoring. Some of the doctors we
interviewed felt that the once a year training they received was inadequate and
others added that this problem is compounded by the lack of continued support
following the training to further improve their skills. According to the WHO,
“A continuous partnership between the trainees and the trainers is
important in maintaining and improving skills, and in acquiring new
skills.”[211]
Dr. Khisa Wakasiaka, a fistula surgeon and trainer working with AMREF, told
Human Rights Watch: “Mentoring and monitoring those surgeons who are
trained is a challenge. It’s difficult to follow up on them to find out
how they are doing and help them to further develop their skills.”[212]

Women normally have to travel long distances to reach the
few facilities that conduct fistula surgery. Women and girls need transport
money, and often, if they have never travelled out of their villages, they may
want to be accompanied by a relative. Some women may be deterred from going to
hospitals far away from their homes. One health provider told us, “Women
find far away hospitals alien. There is fear of not knowing where you are
going; not knowing what to do.”[213]
Two women told us that when they were told they could get treatment at KNH,
they feared going there because it is in Nairobi and they do did know anyone
there.[214] A
nurse confirmed that women fear traveling far for treatment: “Women ask,
‘how do I get there? Who will I stay with? Who [will] I talk
to?’”[215]

Health System Financing,Funding for
Maternal Health Care and Fistula Repairs

Kenya is obliged under international law to take steps, to
the maximum of its available resources, to progressively realize the right to
health. This requires making appropriate allocations from available budgets to health
care, including reproductive and maternal health services. One measure of the
adequacy of health care is its accessibility, including in terms of cost. International
law also requires that the government provide free services where necessary to ensure
women’s right to safe motherhood.[216]

The fact that poor women and girls and those residing in rural
areas continually fail to access maternity and reproductive health services due
to cost constraints implies the government has not been successful in ensuring
equitable access to health.

The government has put in place policies such as waivers and
exemptions for poor women and girls who cannot afford health charges, but these
are ineffective in removing barriers to financial accessibility in cases where women
continue to be charged informal user fees, are not aware of the waivers or
exemptions, or are sometimes denied them. Lack of adequate oversight mechanisms
to monitor and evaluate implementation of these and other policies undermine
the progressive realization of the right to health.

A variety of mechanisms are used to fund public health
services in Kenya, in line with the 1994 health policy framework: taxation,
through the government of Kenya budget; development partner funding; and
cost-sharing with users, both through insurance and through user fees.[217]
The government has recently initiated policy changes aimed at improving health
care financing. Efforts include expanding the output based approach (discussed
in more detail below), to expand benefits under the National Hospital Insurance
Fund (NHIF) to cover outpatient health services and to include people in the
informal labor sector.[218]The focus of NHIF has been mainly on formal sector
employees. This has left out many Kenyans working in sectors such as the informal
sector, agriculture, and pastoralists. The government plans to transform the
current NHIF to a National Social Health Insurance Fund (NSHIF) as a way of
ensuring equity and access to health services by all Kenyans, especially the
poor and those in the informal sector.[219]

The budget is the government’s single most important
policy instrument as it shows the true priorities of the government. The budget
can reveal whether the government is serious about its commitment to improving maternal
and reproductive health care by allocating the necessary resources. Further,
the budget can show whether funds are targeting the real challenges of and gaps
in reducing maternal mortality and morbidity.[220]
Human Rights Watch is not in a position to do a detailed analysis of the
budget. However, generally, funding for the health sector is considered inadequate
by many, including donors, health providers, and government officials.[221]
The Kenya government’s own policies and documents indicate insufficient budgetary
allocation as a key and longstanding challenge to improving health service
delivery.[222] There
is no Kenya government budget allocated to fistula. Funding for fistula repair
services is all from foreign donors, although UNFPA channels its resources
through the government. Government support for fistula repairs includes
provision of hospital space and staff such as nurses and anesthetists.

There is no direct budget line for maternal and reproductive
health, save for family planning. The health budget does not provide details of
what aspects of maternal and reproductive health are funded by the government.
In addition, in Kenya, drugs for all medical conditions, including maternity-related
ones, are centrally bought, and this type of expenditure is not reflected in
the health budget.[223] The
above make it difficult to determine what percentage of the health budget is
being allocated to maternal health care and what areas are prioritized, and
whether these are in line with interventions needed to reduce maternal
mortality and morbidity. The Kenya government should develop a clear budget
line for maternal health, with a particular focus on the poor and those living
in rural areas. In addition, it should establish a system to track annual
budget allocations for maternal health care, including information on what
proportion of the health budget and total government budget is allocated to reproductive
and maternal health care.

Lack of Reintegration Assistance

The World Health Organization recommends that countries
addressing obstetric fistula attend to the reintegration and rehabilitation
needs of women and girls who have undergone repair.[224]
Women need continued emotional and psychological support to ensure they regain
self-esteem and happiness, to ensure reduced stigma and participation in social
and religious life, to regain fertility and sexual life as desired, and to
ensure future safe deliveries after fistula repair. While there have been
achievements in making treatment available, the above needs are not being
addressed. Currently there are no initiatives by the government or other
service providers to facilitate social reintegration into the community.[225]
One doctor commented, “Now the interest is in surgery, tell me, who is
doing rehabilitation? So the cause of the fistula may be social and economic.
You do the surgery meticulously and you release the women into same environment
which gave her the fistula and the factors are still in operation. We have seen
women repaired. They go and heal and come back with another fistula.”[226]

Support for reintegration is particularly vital for women
experiencing high levels of stigma, those with unsuccessful repairs, or those
who are not continent after repair. Women and girls can experience stress
incontinence after repair; this can be very traumatic and women may think the
surgery was unsuccessful. The consequences may be the same as with actual
fistula.[227]
Furthermore, women with such conditions may continue to experience stigma,
discrimination, and even violence.

Costs to Users in the
Public Health System

Poverty is one of the main
reasons some women and girls cannot access quality maternal care services.
Kenya is ranked 147 out of 182 countries on the United Nations Development
Programme’s Human Development Index.[228]Per
capita income is roughly US$770 per year, which is about $2 per day.[229]Forty-six
percent of Kenyans are living below the food poverty line.[230]The
country has been hard-hit by rising fuel prices, in turn affecting transport
costs and food prices. According to the Health Financing Policy and Strategy,
out-of-pocket health expenditure is high in Kenya, particularly among rural and
poor populations, and accounts for a large share of total health expenditure.[231]

User Fees

User fees, as part of cost-sharing in the health sector in
Kenya, have been operational since 1992. In an effort to lessen the negative
impact of user fees, Kenya introduced a user fees reduction policy in 2004
commonly referred to as the 10/20 policy, which made health services from the
lowest-level facilities (dispensaries and health clinics) very affordable. Under
the policy, services at dispensaries and health centers are to be free for all
citizens, except for a minimum registration fee of KSH 10 at dispensaries and
KSH 20 at health centers (approximately $0.13 and 0.27 respectively).[232]

Removing user fees for maternity services can greatly
improve access to care.[233]
Kenya has taken the important step of making childbirth free in dispensaries
and health centers, but there is a charge for delivery in higher-level public
hospitals. There, charges for normal delivery range from KSH 1,500to
KSH 3,000 (roughly $20 and $40) while Cesarean section births average KSH 6,000
to KSH 8,000 (approximately $80 to $106).

The cost of fistula surgery in public hospitals is about the
same as for a Cesarean section operation. These fees exclude the cost of
transportation to the hospital and post-operative care that is vitally
important to prevent infection. User fees create a significant barrier to
women’s access to quality reproductive and maternal health services and
put them at risk of death or injury when they are forced by poverty to deliver
at home under unskilled care. Except for the few who hear announcements about
free fistula repair camps, cost can deter women living with the condition from
seeking treatment.

User Fee Exemptions

The government has implemented a user fee exemption policy.[234]
In addition to childbirth in dispensaries and health centers, other services
exempted include treatment of children aged below five years, and care for
specific health conditions such as malaria, antiretroviral treatment for
HIV/AIDS, and tuberculosis.[235]

Fully exempt reproductive health services in all levels of
government facilities include antenatal care, postnatal care, and family
planning. A proposal for a broader maternal health care exemption, which would
make delivery in all government facilities free, by the former Minister for
Health, did not succeed.[236]
Although supposedly an exempt service, women do incur both formal and informal
fees when accessing family planning services.[237]
The government has not instituted monitoring mechanisms to ensure that health
facilities do not charge for exempt services.[238]

User Fee Waivers

The government has implemented a general waiver system in
public facilities for those who cannot meet their medical costs. The policy
says: “A waiver … is a release from payment based on
financial hardship at a particular point in time and it is not
automatic. Patients must request a waiver and judgment must be made as to
whether or not the patient is truly a hardship case.”[239]
The aim of the policy is to “ensure that no patient is denied essential
health care because of inability to pay.”[240]
Priority is supposed to be given to vulnerable groups such as children under
the age of five, street families, maternal and child health services, and
referral cases.[241]
There are no defined health providers authorized to grant waivers. The hospital
administrator is charged with the duty of assigning responsibility to grant
waivers.[242] Human
Rights Watch interviews with two government officials, doctors, and nurses indicate
that waivers are administered by a wide range of health providers, including medical
social workers, health administration officers, and nursing officers.[243]

Human Rights Watch found that implementation of the waiver
policy is poor for a number of reasons. The criteria for determining the
financial need of a patient—such as mode of dress—are vague and
easily manipulated by patients and hospital reviewers.[244]
Furthermore, hospitals do not always publicize the availability of waivers
despite a government requirement to do so.[245]
The three public hospitals visited by Human Rights Watch did not tell patients
that they could apply for waivers. Hospitals fear misuse of the waiver service,
hence the failure to publicize. Emily Wasungu, the nursing officer in charge of
the labor ward at Kisumu Provincial General Hospital told us, “We
don’t give them information because it can be misused.”[246]
Another health provider had a similar comment: “[There are] big fears on
misuse of service.” He explained: “Patients want the waiver all the
time and tell friends and relatives. Staff members misuse the waiver. Chiefs [community-level
provincial administrators] write letters for people who are not in need and
patients will go extra miles such as dressing in old clothes to appear
poor.”[247]
A government official told us, “Members of staff in a good number of
hospitals collude with or try to influence decisions on waiver.”[248]

For the waiver system to be effective in enhancing access to
health care for the poor, the population should be informed about the existence
of such a policy. Almost all the women we spoke to had never heard about the
waiver policy. One woman had asked for a waiver in a hospital and was told it
did not exist:

I asked at Machakos if they could do the repair for free
because I did not have any money and I was told I needed KSH 6,000 ($80). But I
had no money.… I asked the nurse, “I hear you can help poor
people.” She told me, “That [does] not happen here.” My only
option was to sell land but I would rather stay with the problem than sell my
land because it is my only source of food.[249]

Although one of the doctors said he had obtained a waiver
for a woman needing fistula surgery,[250]
our research found that the waiver system has not made a great difference in
ensuring poor women and girls access maternal health services. Addressing cost
as a barrier to fistula repair, Dr Josephine Kibaru, the head of the Department
of Family Medicine in the Ministry of Public Health and Sanitation noted that
majority of fistula survivors are poor and remarked, “There should be no
discussion. These [fistula survivors] are waiver cases.”[251]

Health care facilities usually absorb the costs of both
administering the waiver system and providing the services they have waived,
limiting its effectiveness:

The important role for user-fees as a
mechanism for healthcare financing is curtailed largely due to lack of third
party payment for the cost of waivers and exemptions instituted to protect and
guarantee access by the needy. As a result, the fee levels have been kept low,
thereby undermining its revenue generating potential, and consequently its
ability to support increased provision and availability of quality services.[252]

Another problem in the implementation of waivers is that some
health care users tend to have little knowledge about the existence and
implementation of the waiver system. Although the waiver policy says that
hospitals should assign people responsibility to grant waivers, our interviews
with nurses, doctors and hospital administrators show that this is not always
the case. While many of them knew about the existence of the waiver policy,
some of them could not tell us the process of obtaining a waiver or who, in
their respective health facilities makes the decision to grant the waiver. A
government official acknowledged that these information gaps exist and
commented, “It is true that some staff are not aware [about the
application of the waiver policy]. Those that were trained have left. We
realize the need for catch-up training.”[253]

The Kenya government should publicize the existence of the
waiver system and procedures for obtaining one. All health facilities should be
required to publicly display such information. The government should also
develop and implement mechanisms to monitor health facilities’ compliance
with the waiver policy.

VI. Patients’
Rights and Health System Accountability

Health system accountability has
received little attention in Kenya. Accountability in the context of the right
to the highest attainable standard of health “is the process which
provides individuals and communities with an opportunity to understand how
government has discharged its right to health obligations. Equally, it provides
government with the opportunity to explain what they have done and why.”[254]
Accountability is central to women’s right to health and to
reducing preventable
maternal mortality and morbidity. It begins with the government ensuring the
incorporation and implementation of accessible, easily understood, and
effective accountability processes into the health system.

Several processes enhance health
system accountability. Grievance redress is key. When women are mistreated in
health facilities or when they are unhappy about the quality of services
offered, it is important that they have access to effective mechanisms to
address concerns or complaints. Such mechanisms would not only enhance their
trust in the health system but also improve utilization and effectiveness of
maternal health services. Another component of health system accountability
involves ensuring non-recurrence of systemic failures and gaps. Persistent
problems with access to emergency obstetric care, mistreatment by health
providers or poor referral systems indicate accountability deficits.

Mistreatment and Neglect
by Health Care Providers

Abuse of women in health facilities when they go to deliver
is a longstanding problem in the Kenya health sector. Although Human Rights
Watch interviewed few women who had been abused during delivery, a study
looking exclusively at abuse of women during childbirth by the Federation of
Kenya Women Lawyers (FIDA Kenya) and the Center for Reproductive Rights
documented decades of rights violations including verbal and physical abuse.[255]

Abuse of women during labor often coincides with negligence
in providing care. We spoke to women and girls who told us that they were left
unobserved for many hours at health facilities. When 17-year-old Akello Z.
started labor in 2007, her grandmother immediately called a TBA. Two days
later, she had not delivered and her grandmother borrowed money to take her to
the nearest dispensary, but she found no help there: “We got to the
dispensary at about midday. I was examined by a nurse and she said I had to wait.
I was near to deliver. I stayed at the dispensary until the following day at
around 7 a.m. The nurse just left me alone and told me ‘next time you
will think when you are enjoying sex.’ In the morning she did not check
me. She just said they could not help me and I should go to another
hospital.”[256]
Awino A. (abuse case described above) told us, “They kept telling me to
push. After some time they left me alone. At night no one came to see me at
all. At around 5 a.m., a doctor came to the ward and was shocked and asked the
nurses why they had kept me for so long without referring me and the baby was
dead.”[257]
Another woman narrated her ordeal to us,

I started labor at about midnight. I told my sister-in-law
and she immediately took me to the general hospital which is about half an hour
walk from where we were staying. At the hospital they examined me and said I
was not due but I was in so much pain and the water had already broken. The
nurse took me to the labor ward and told me to push but the baby was not coming
out. I was in pain for three days. On the third day they called a doctor who
came and pulled out the baby using a metal [forceps] because the baby was
already dead.[258]

A senior government official told us: “We have started
this process of visiting hospitals. We were in Webuye in October [2009] and
went to the labor ward and found one pregnant woman in the labor ward who had
stayed for two days and had not been reviewed.”[259]

In 2002, in collaboration with various professional bodies,
the Ministry of Health developed Standards for Maternal Care in Kenya that aim
to provide women with “good quality care
… [ensure] dignity during childbirth ... prevent the aspects of care that
are disrespectful and unnecessary which will impact negatively on the
confidence of women in using a specific facility.”[260] The standards state as an outcome criteria that women
“are not addressed rudely.”[261] The Standards for Maternal Care also stipulate
that, “Every woman in labour in a health facility [be] monitored with a
partograph [or] … [be] delivered or referred within 1 hour of diagnosis
[with obstructed labor].”[262]
Generally, use of partographs—charts for monitoring progress of
labor—is low. An assessment survey of health facilities in 2004 found
that “39 percent of facilities offering delivery services have blank
partographs.”[263]

Substandard care happens at all levels of facilities. A
study by UNFPA and the Population Council that included a review of hospital
records of women in obstructed labor who underwent Cesarean sections concluded
that the “quality of care in referral facilities requires
improvement.”[264]
For example they found that, “Blood for grouping and cross matching was
taken in 76 percent of the cases but worryingly in only 37 percent of the cases
were IV fluids commenced once diagnosis of obstructed labour was made. Only
half of the case notes reviewed was a urinary catheter inserted prior to
C/S.”[265]
More than half of health care providers interviewed by Human Rights Watch
confirmed the occurrence of these failings. Some, especially nurses, linked
them to poor working conditions. One nurse commented, “Provider attitude
is a problem especially with young girls.... You meet one nurse taking care of
70 patients. In the morning you are just crazy.”[266]
A doctor told us, “In North Eastern, you find one nurse attending to
women, children, and men. How can she offer good care?”[267]
Another one said, “It is true that some nurses neglect patients, but in
some cases it is capacity issues. Our dispensaries and health centers and even
hospitals are so poorly staffed. You wonder when this problem will end.”[268]

Bad treatment of women and girls in health facilities can
have indelible psychological effect and deter women from using health
facilities in general. In the case of fistula, it can deter them from going for
follow-up care or seeking further medical treatment in case of unsuccessful
surgery. Muthoni M. had a negative experience when she took her child to Embu
Provincial hospital in 2007. When she got fistula in 2009, she did not go to
hospital for fear she would not be helped: “They just toss you from one
person to another. I was referred there to take the baby because she had
diarrhea and a cough. The child was very ill. Instead they kept me waiting. I
had to go back home. They talk very badly. They don’t even care. I could
not go back there.”[269]
A nurse at Railways Dispensary in Kisumu observed, “If a mother goes to a
facility and she is not helped, it stops other women from going.”[270]

Inadequate Patients’
Rights and Grievance Mechanisms

Despite documented evidence of abuse and neglect in the
health sector in Kenya, no effective formal mechanisms have been developed to
respond to grievances and provide redress when patients’ rights are
violated. Accountability includes the monitoring of conduct, performance, and
outcomes. In this regard, and in order to correct systemic failures in reducing
maternal morbidity and mortality and thereby assist the government to
progressively realize the right to health, it is important to get feedback from
patients on the quality and acceptability of services provided. There should be
accessible and effective ways of providing such feedback, lodging complaints,
and ensuring such feedback it acted upon. This requires the government to
inform patients about their rights and entitlements and how to access redress
mechanisms. By not adequately providing information about entitlements under
existing healthcare policies and by failing to implement effective grievance
redress procedures, the government is falling short of its obligation to
guarantee the right to a remedy.

Service Charter for Health Service Delivery

The two ministries of health have a “Service Charter
for Health Service Delivery.” It states,

The Government is committed to provision of efficient and
high quality health care that is accessible, equitable and affordable to every
Kenyan…. The purpose of this charter is to provide the public with our
core functions and values, information on the range of services we offer, our
commitments, principles, obligations, customers’ rights and obligations,
mechanisms for complaint and redress for any dissatisfied clients and
customers.[271]

However, the charter does not explain when, how, and to whom
patients can complain, nor does it talk about redress.

Citizens’ Service Charters

The two health ministries have also developed
Citizens’ Service Charters. The Ministry of Public Health and
Sanitation’s (MoPHS) “Citizens Service Delivery Charter”
promises “to provide quality preventive and promotive health services to
all our clients with dignity, professionalism and within the shortest time
possible.”[272]
It gives a list of services rendered, the patient responsibilities, user
charges, and the expected waiting time. In addition, it spells out health
services that are exempt from payment including deliveries in dispensaries and
health centers, but it does not mention family planning services.

The Ministry of Medical Services
has developed a “Citizens Service Charter for Delivery of Medical
Services for District Hospitals,” which is more elaborate than the MoPHS
one. It advises patients that they can complain about unsatisfactory services
and where they can do so: “Any service that does not conform to the above
standards or an officer who does not live up to the commitment to courtesy and
excellence in service delivery should be reported to the Out-Patient Department
Nursing Officer in-charge or any Hospital administrator.”[273]
It says that childbirth is only free in health centers and dispensaries.
However, it does not indicate that family planning, antenatal care, and
postnatal care are also free.

Patients’ Rights Charter

In 2006, the Ministry of Health developed a patients’
rights charter[274]
that hospitals are supposed to display strategically, but, based on facility
visits by Human Rights Watch, this is not always done. Also, there seems to be
no effort to enable illiterate patients to understand their rights and to lodge
grievances. There are no public awareness campaigns on patients’ rights
and grievance mechanisms. A government official confirmed that patients are not
educated about their rights:

Something that the ministry started but has not expanded is
the patients’ rights. Public health education also died along the way.
There is this poster [he shows a poster that talks about patients rights and
that he says should be displayed in hospitals] in my office but hospitals are
not showing them. I have been to several hospitals and they don’t show
them.[275]

A nurse at Machakos General Hospital told us,
“Patients can inform the nursing officer at the administration block if
they have grievances against nurses,” but added, “We don’t
tell patients that they can complain. Some read the patients’ rights we
have displayed on the wall.”[276]
She also informed us that she knew of no clear system for dealing with
providers who are reported by patients. Instead, there are ad hoc measures such
as being called before a disciplinary committee and warned.

Suggestion Boxes

Even patients who are aware of their rights and feel
aggrieved at how they are treated in health facilities have limited ways of
registering and processing complaints. The current system of using suggestion
boxes is ineffective. All the hospitals we visited had a suggestion box. When
we asked various hospital staff how they used this system to address
grievances, for example the types of complaints received, processes to deal
with them, and their outcomes, most did not know how this system worked.
According to a government respondent, “There is a structure but it is not
being followed.… Hospitals should have complaint boxes, at least four,
strategically displayed in hospitals. These need to be reviewed by advisory
committees but this is not being done.”[277]
The Director of Public Health in the Ministry of Public Health and Sanitation
concurred: “[The] complaint mechanism is not effective. Patients
don’t complain.”[278]

Some women and girls interviewed by Human Rights Watch
reported that they were too afraid to complain against doctors or nurses even
when they felt that they had experienced some injustice for fear of reprisals.
One told us, “Some nurses were not good to me at the hospital. They
refused to change my beddings telling me why don’t you use the things
that people use at home to stop the urine from coming out. I did not complain
because I feared they will not treat me.”[279]

Accountability and the Community Strategy

One of the objectives of the
Community Strategy is “Strengthening the community to progressively
realize their rights for accessible and quality care and to seek accountability
from facility based health services”[280]
by ensuring that health providers adhere to the Citizen’s Service
Charters.[281]
The Community Strategy is a good avenue to educate communities about their
rights and to link communities with health facilities to strengthen existing
systems. As one health NGO worker noted, “Strengthening accountability
“[C]an be very helpful…. Not everything can be solved by [reducing]
the costs [of maternity care].”[282]
Or, as another health professional observed, “It [accountability] will
address the impunity culture of ‘even if I don’t help you, what
will you do?’”[283]

VII.Detailed Recommendations

To the Ministry of Public Health
and Sanitation and the Ministry of Medical Services

On a National Fistula Strategy

·Develop
and implement a national fistula strategy in accordance with the World Health
Organization’s “Obstetric Fistula: Guiding Principles for Clinical
Management and Programme Development.” Other relevant government
ministries, such as the Ministry of Gender and Children Affairs, and NGOs
should participate in the conception of the strategy.

On Fistula Awareness and Education

Carry out an awareness-raising campaign to inform the
public about the causes of fistula, contributing factors and risks (such
as female genital mutilation, early marriage and childbearing, and lack of
skilled care at delivery), and the availability of treatment. Involve
provincial administrators, religious leaders, and NGOs in the campaign.

Incorporate information about fistula and availability of
treatment services into the “Malezi Bora” (child-mother health
and nutrition campaign) weeks.

Integrate information on fistula into the Community Strategy
by:

Strengthening messages in the Community
Strategy on pregnancy and childbirth by developing specific messages on
obstetric complications, including obstetric fistula, and translate these into Kiswahili
and local languages.

Training community health extension workers
and community health workers to educate communities about fistula, and to
identify and refer for treatment women and girls with fistula.

Integrate fistula information, including on
facilities where treatment is available, into in-service training of health
providers, and into antenatal and postnatal care services.

Encourage nongovernmental organizations who work with
communities on reproductive and maternal health issues to incorporate
fistula awareness into their programs.

On School-Based Sexuality Education

Make comprehensive sexuality education part of the school
syllabus so that teachers can allocate time to teach it.

On Economic Access Barriers to Maternity Services and Fistula Treatment

Assess the feasibility of exempting fees for maternal
health care in all health facilities beyond the current exemption for
childbirth in dispensaries and health centers.

Prioritize the completion and implementation
of the National Social Health Insurance Fund to improve women’s access to
maternal health care.

Publicize the cost of maternal health services:

Include in the Citizen’s Service
Charters the cost of all maternity services and indicate which services are
exempt from payment, and translate it into Kiswahili and local languages.

Require that all health facilities display
the Citizen’s Service Charters in strategic locations and monitor
compliance.

Publicize the existence of the waiver system
and procedures for obtaining a waiver, including through translating these into
Kiswahili and other local languages, and requiring facilities to display them.

Monitor facilities to ensure that user fees
are charged as outlined and exemptions and waivers are applied. Collect
gender-disaggregated data on this.

On Budgeting for Maternal
Health Care

Establish a system to track annual budget allocations for
maternal health care, including information on what proportion of the
health budget and total government budget is allocated to reproductive and
maternal health care.

On Access to Emergency
Obstetric Care and Health System Strengthening

Urgently strengthen emergency obstetric care by:

Scaling up the number of health facilities
that offer emergency obstetric care and intensifying efforts to meet the
recommended ratios for staffing in health facilities.

Developing and implementing guidelines on
the management of obstructed labor and oversight of this health service in line
with the WHO’s handbook on monitoring emergency obstetric care.

Conducting refresher training for health
providers and monitoring the use of partographs in health facilities, and widely
disseminating and monitoring implementation of the Standards for Maternal Care.

Implementing the referral component of the
Community Strategy, including strengthening education on male involvement in
birth planning and emergency preparedness.

Improving communication between communities
and community health facilities, through provision of toll free emergency
numbers.

Improving emergency transport between
facilities by providing more ambulances, especially to service dispensaries and
health centers.

Prioritizing the completion and
implementation of the referral strategy.

On Facilities and Training of Fistula Surgeons

Work with the University of Nairobi and other institutions
that train doctors and nurses to ensure that obstetricians and
gynecologists get adequate skills on fistula identification during
training, and support the training of adequate numbers of surgeons.

Provide necessary equipment and supplies to hospitals that
have trained fistula surgeons to facilitate routine repair.

Work with donor partners to support long-term mentoring of
surgeons undergoing fistula training.

On Fistula Data Collection and Monitoring

Develop a tool for routine obstetric fistula data
collection in health facilities and in communities through community
health workers and community health extension workers.

To the African Union
Commissioner for Social Affairs

To the United Nations
Population Fund

Expand
prevention activities of the Campaign to End Fistula and intensify work on
rehabilitation and reintegration of fistula survivors.

Offer the Kenya government technical and financial support
to conduct
further research on the prevalence and incidence of fistula.

Expand
efforts to train selected women who have had successful surgery to be
community educators and support them to do so.

Work
with the African Union to integrate fistula into the Campaign for
Accelerated Reduction of Maternal Mortality in Africa.

To the United Nations
Children’s Fund

Support
NGOs and civil society organizations to raise public awareness about the
dangers of early marriage and female genital mutilation, including obstetric
fistula.

Encourage
and support provision of systematic, comprehensive sexuality education for in-
and out-of-school adolescents.

Consider
supporting, as part of protection work, rehabilitation and reintegration into
communities of girls who have undergone fistula repair.

To Donor Countries
and International Agencies

Continue
to offer the Kenyan government technical and financial support to address health
system gaps that lead to poor quality maternal health care.

Support efforts to improve access to health care through
improved health financing systems. In particular, support steps to make reproductive
and maternal health care services more affordable.

Continue to offer the Kenyan government technical and
financial support to improve emergency obstetric care, and prioritize
improved access by poor, illiterate, and rural women.

Provide technical and financial assistance to ensure that
all government health interventions, particularly interventions funded by
them, are monitored and evaluated to ensure that they are reaching poor,
illiterate, and rural women.

VIII. Appendix I

Relevant Health Sector Policies, Strategies, and
Guidelines

National Reproductive Health Policy (NRHP)

In 2007, Kenya’s first-ever NRHP was developed to
complement the NRHS (see below) by providing a
framework for equitable, efficient, and effective delivery of high-quality
reproductive health services throughout the country with an emphasis on
reaching those in greatest need and most vulnerable.[284]
It has four main areas of focus: safe motherhood, maternal and neonatal health,
family planning, and adolescent/youth sexual and reproductive health and gender
issues.

The NRHP states that traditional birth attendants “are
not recognized as providers of skilled care,” and they should be used as
advocates of safe childbirth through encouraging and referring to health
facilities women who seek their services.[285]

The National
Reproductive Health Strategy (NRHS) 2009-2015

The Government launched the National Reproductive Health
Strategy (NRHS) 2009-2015 to “[F]acilitate operationalization of the
National Reproductive Health Policy.”[286]
In addition, the strategy aims to improve financing for reproductive and
maternal health care and to facilitate implementation of the reproductive and
maternal health aspects of the Community Strategy.[287]
Some of its objectives are to markedly reduce maternal mortality rates, to
ensure the presence of skilled attendants at 90 percent of deliveries, and to
have all health facilities providing basic emergency obstetric care, all by the
year 2015.[288]

National Road Map for Accelerating
the Attainment of the MDGs Related to Maternal and Newborn Health in Kenya

In 2007, the Ministry of Medical Services and Ministry of
Public Health and Sanitation developed the MNH Road Map, “To accelerate
the reduction of maternal and newborn morbidity and mortality towards the
achievement of the Millennium Development Goals (MDGs).”[289]
It has three objectives: to “[i]mprove data management
for decision making and utilisation in health planning,” to
“increase the availability, accessibility, acceptability, and utilisation
of skilled attendance during pregnancy, childbirth and the post partum period
at all levels of the health care system,” and to “strengthen the
capacity of individuals, families, communities, social networks to improve
maternal and newborn health.” The Road Map identifies obstetric fistula
as a big problem and indicator of poor maternal health services but does not
explicitly address fistula in its strategies.

Standards for Maternal Care in
Kenya

These standards were developed by professional bodies
(National Nurses Association of Kenya and the Kenya Obstetricians and
Gynaecologists Society). They provide guidelines for handling emergency
obstetric cases with the hope that “improved quality of care will
increase clients’ satisfaction as well as … use of services and
thus help to reduce maternal and perinatal mortality and morbidity.”[290]
The section on management of women and girls who present with obstructed labor
does not include important details, such as the need to insert an in-dwelling
catheter, which can help with spontaneous closure of small fistulas.

Family Planning

Many policies and strategies on reproductive and maternal
health address the importance of family planning in enhancing the health of
women and children. The Family Planning Guidelines for Service Providers were
first developed in1991.[291]
The guidelines were revised in 2005 to assist service providers in
maintaining comprehensive care for clients seeking family planning,
including the provision of youth-friendly services and linkage of family
planning and HIV/AIDS services, and in 2010 to reflect the 2009 medical
Eligibility Criteria of the World Health Organization.[292]

Adolescent
Reproductive Health and Development Policy

Kenya has put in place an Adolescent Reproductive Health and
Development Policy (ARH&D) policy to enhance the implementation and
coordination of programs that address the reproductive health and development
needs of young people. The policy addresses adolescent health issues such as
sexual health and reproductive rights, harmful practices, drug and substance
abuse, socio-economic factors, and the special needs of adolescents and young
people with disabilities. Some of its targets are: to increase the proportion
of facilities offering youth-friendly services to 85 percent, to reduce the
proportion of women aged below 20 with a first birth from 45 percent in 1998 to
22 percent and to raise the median age of fist sexual intercourse from 16.7 for
girls and 16.8 for boys to 18 for both, all by 2015.[293]
The ARH&D Plan of Action 2005-2015 has been developed to guide
implementation of the policy.[294]

Youth-Friendly
Services

The National Guidelines for Provision of Youth-Friendly
Services (YFS) in Kenya outlines the role of the health sector in addressing
the special reproductive health concerns of young people.[295]
It outlines strategies, approaches, and models for delivery of YFS.

Kenya’s second National Health Sector Strategic Plan
(NHSSP II – 2005–2010) defined a new approach to the way the sector
will deliver health care services to Kenyans: the Kenya Essential Package for
Health (KEPH). KEPH represents the integration of all health programs into a
single package that focuses its interventions toward the improvement of health
at different phases of the human development cycle. These phases represent
various age groups or cohorts, each of which has special health needs. These
services are provided at each of the six levels of the healthcare system.

IX. Acknowledgements

Agnes Odhiambo, researcher in the Women’s Rights
Division at Human Rights Watch, wrote this report based on research that she
conducted with Janet Walsh, deputy director of the Women’s Rights
Division, in Kenya in November and December 2009. Janet Walsh, Juliane
Kippenberg, senior researcher in the Children’s Rights Division, Joseph
Amon, director of the Health and Human Rights Program, Ronal Peligal, acting
director of the Africa Division, Aisling Reidy, senior Legal Advisor, and
Cassandra Cavanaugh, consultant to the Program Office reviewed the report.
Charlotte Warren, Population Council, provided external review.

We are grateful to the women and girls who agreed to share
their stories with us and we admire their courage and resilience. Human Rights
Watch appreciates the support of the fistula surgeons who linked us with the
women and girls for interviews.

We also thank the many individuals and organizations that
contributed to this report with their time, expertise and information.

The Women’s Rights Division of Human Rights Watch
gratefully acknowledges the financial support of Arcadia, the Moriah Fund, the
Trellis Fund, and other supporters.

[1]
The three public hospitals were level 5 hospitals. Kenya’s health care
system is organized in six levels. Level 1 is the community Level. It consists
of using community-owned resource persons and community health and extension
workers in health promotion. Level 2 and 3 consist of primary health services,
where health promotion and basic treatment services are provided. Only simple
diagnostic and short term in-patient services, such as maternity and short
recuperative observations are provided at this level. Major treatments are
offered in Levels 4 and 5, which comprise sub-district, district and provincial
general hospitals. These also serve as referral facilities for Levels 1, 2 and
3. Level 6 are the national referral and teaching hospitals. Ministry of Public
Health and Sanitation and Ministry of Medical Services, “Referral
Strategy and Investment Plan for Health Services,” July 2008-June 2012,
p. 25. Machakos and Kisii general hospitals were recently upgraded to level 5
facilities. This report has retained the names Machakos General Hospital and
Kisii General Hospital for readability.

[2]
The Convention on the Rights of the Child defines a child as anyone under the
age of 18 years. The Kenya Children’s Act has a similar definition. Convention
on the Rights of the Child (CRC), adopted November 20, 1989, G.A. Res. 44/25,
annex, 44 U.N. GAOR Supp. (No 49) at 167, U.N. Doc. A/44/49 (1989), entered
into force September 2, 1990, art. 1, and the Children’s Act, No.8 of
2001, Laws of Kenya, art. 2. We interviewed 12 girls with fistula.

[3]
Globally, approximately 80 percent of all maternal deaths are estimated to be
caused by direct obstetric causes (hemorrhage; sepsis; hypertension; unsafe
abortions; and obstructed labor). Indirect causes include HIV/AIDS, malaria,
anemia, and tuberculosis. In countries with high HIV or tuberculosis
prevalence, the proportion of indirect causes could be higher. Millennium
Project, Task Force on Child Health and Maternal Health, Who’s Got the
Power? Transforming Health Systems for Women and Children (London:
Earthscan, 2005), http://www.unmillenniumproject.org/documents/maternalchild-frontmatter.pdf
(accessed February 2, 2010), p. 80. No single health intervention can by itself
significantly reduce maternal deaths. Programs that link services for women
from adolescence through pregnancy, delivery, and after delivery are needed.
Health experts generally agree that increasing access to family planning, antenatal
care, having skilled health workers assisting at birth, and access to emergency
obstetric care can greatly reduce maternal deaths and morbidities. See World
Health Organization (WHO) et al., The Millennium Development Goals Report
(New York: United Nations, 2009), www.un.org/millenniumgoals/pdf/MDG%20Report%202009%20ENG.pdf
(accessed October 10, 2009), p.27, and Millennium Project, Task Force on Child
Health and Maternal Health, Who’s Got the Power?, pp. 80-89.

[4]
WHO et al., Maternal Mortality in 2005: Estimates Developed by WHO, UNICEF,
UNFPA and The World Bank (Geneva: WHO Press, 2007), www.who.int/whosis/mme_2005.pdf (May 3, 2010),
p. 15. New estimates of global maternal mortality are currently being finalized
by WHO, UNICEF, UNFPA and the World Bank, and are expected to be released in
mid-2010 according to the current Millennium Development Goals Report. See WHO
et al., TheMillennium Development Goals Report, p. 30.

[6]
Ibid., p. 6. The study notes that the decline reflects progress only in some regions,
and very little progress has been made in sub-Saharan Africa, where women face
the greatest lifetime risk of dying as a result of pregnancy and childbirth. The
study notes wide regional and country variations in maternal mortality ratio
decline, adding that only 23 countries are on track to achieve MDG 5 on
maternal health, and that the proportion of maternal deaths in sub-Saharan
Africa increased vis-à-vis the rest of the world. The maternal mortality
ratio is defined as the number of maternal deaths in a population divided by
the number of live births. Thus, it depicts the risk of maternal death relative
to the number of live births. See also, WHO et al., The Millennium
Development Goals Report, p.27.

[7]Estimates
on the number of women who develop maternal morbidities vary. See Millennium
Project, Task Force on Child Health and Maternal Health, Who’s Got the
Power?, p. 80. The WHO estimates that 30-50 times as many women suffer from
maternal morbidities as die from pregnancy and childbirth. A fact sheet from
the Partnership for Maternal, Newborn, and Child Health says about 30 women
develop complications for every woman that dies from pregnancy and childbirth.
Partnership for Maternal, Newborn, and Child Health, “Fact Sheet:
Maternal Mortality (Millennium Development Goal MDG 5),” undated, http://www.who.int/pmnch/media/press_materials/fs/fs_mdg5_maternalmortality/en/index.html
(accessed April 30, 2010).

[9]There is no single cause of death and
disability for men between the ages of 15 and 44 that is close to the magnitude
of maternal death and disability. Paul Hunt and Judith Bueno De Mesquita, Reducing
Maternal Mortality: The Contribution of the Right to the Highest Attainable
Standard of Health (New York: United Nations Population Fund (UNFPA) and
University of Essex, 2007),
http://www.unfpa.org/upload/lib_pub_file/750_filename_reducing_mm.pdf (accessed
October 2, 2009), p. 4.

[10]Other
past initiatives include the 1987 Safe Motherhood Initiative and undertakings
stemming from the 1994 International Conference on Population and Development.

[12]
European Parliament, “Resolution on Maternal Mortality ahead
of the UN High-level Event on the Millennium Development Goals to be held on 25
September 2008,” RSP/2008/2621, September 4, 2008, http://www.europarl.europa.eu/sides/getDoc.do?pubRef=-//EP//TEXT+TA+P6-TA-2008-406+0+DOC+XML+V0//EN&language=EN
(accessed April 26, 2010).

[15]
“Road Map for Accelerating the Attainment of the MDGs Related to Maternal
and Newborn Health in Africa,” 2004, http://www.google.co.ke/search?hl=en&q=The+African+Road+Map+for+Accelerating+the+Attainment+of+the+MDGs+related+to+maternal+and+newborn+health+%28MNH&meta=&aq=f&aqi=&aql=&oq=&gs_rfai=
(accessed April 1, 2010), pp. 1 and 6.

[19]
See United Nations Economic Commission for Africa, “The African Union Deepens Its Campaign for Accelerated
Reduction of Maternal Mortality in Africa,” http://www.uneca.org/acgs/icpd+15/Maternal.html
(accessed October 27, 2009); and United Nations Economic Commission for Africa,
“The African Union Commits to Promoting Maternal, Infant and Child Health
in Africa,” http://www.uneca.org/acgs/icpd+15/BackgroundAU.html (accessed
October 31, 2009).The Campaign’s main objective is to accelerate the availability
and use of globally accessible quality services, particularly those related to
sexual and reproductive health germane to the reduction of maternal and infant
mortality. The African Union partners with WHO, UNFPA, and UNICEF in this
campaign. Ibid.

[20]
WHO, “10 Facts on Obstetric Fistula,” March 2010, http://www.who.int/features/factfiles/obstetric_fistula/en/
(accessed May 16, 2010). Some in-depth studies support the widely held view
that the true number of women living with untreated fistula could be far more
than this estimate. One study has found that in Nigeria alone, as many as one
million women could be living with fistula, and another suggests that 70,000
new cases occur annually in Bangladesh. See WHO, Obstetric Fistula: Guiding
Principles for Clinical Management and Programme Development (Geneva: WHO,
2006),
http://www.who.int/making_pregnancy_safer/publications/obstetric_fistula.pdf
(accessed November 27, 2009), p.4.

[23]The term obstructed
labor indicates a failure to progress due to mechanical problems such as a
mismatch between the size of the presenting part of the fetus and the
mother’s pelvis. Some mal-presentations such as a brow presentation or a
shoulder presentation will also cause obstruction. Pathological enlargement of
the fetal head and ineffective uterine contractions may also obstruct labor.
These different causes of difficult labor may co-exist. J. P. Neilson et al.,
“Obstructed Labour: Reducing Maternal Death and Disability during
Pregnancy,” British Medical Bulletin, vol. 67 (2003), pp. 191-204; Nawal
Nour, “An Introduction to Maternal Mortality,” Journal of
Obstetrics and Gynecology, vol. 1, no. 2 (2008), pp. 77-81; and WHO, Obstetric
Fistula: Guiding Principles for Clinical Management and Programme Development,
p.3.

[25]
Amy Tsui et al., “The Role of Delayed Childbearing in the Prevention of
Obstetric Fistulas,” p. 99. Also see WHO, “Obstetric Fistula:
Guiding Principles for Clinical Management and Programme Development,”
p.3. The report of the UN Secretary-General on obstetric fistula also notes
that early marriage heightens the risks of obstetric fistula. UN General
Assembly, “Supporting Efforts to End Obstetric Fistula, Report of the
Secretary-General,” (sixty-third session, item 59 of the provisional
agenda, Advancement of Women), A/63/222, paras. 9-10. Malnutrition, which
stunts pelvic growth, is another contributing factor to fistula development.

[30]
In the 2008 classification of FGM, WHO defines infibulation as, “narrowing
of the vaginal orifice with creation of a covering seal by cutting and
appositioning the labia minora and/or the labia majora, with or without
excision of the clitoris.” WHO, Female Genital Mutilation and Other Harmful
Practices: FGM Factual Overview and Classification,” http://www.who.int/reproductivehealth/topics/fgm/overview/en/index.html
(accessed May 24, 2010).

[33]See
Doctors of the World, “Partnership for Maternal and Neonatal Health: West
Pokot District Child Survival and Health Program,” October 2007, http://pdf.usaid.gov/pdf_docs/PDACK514.pdf
(accessed April 2, 2010), p.24, noting that traditional birth attendants and
nurses working in West Pokot report that it is standard practice to cut a bilateral
episiotomy in order to facilitate childbirth.

[38]
UN General Assembly, Resolution adopted by the General Assembly on the Report
of the Third Committee (A/62/435), “Supporting Efforts to End Obstetric
Fistula,” A/RES/62/138.

[39]
UN General Assembly, “Supporting Efforts to End Obstetric Fistula, Report
of the Secretary-General.” . Some of the recommendations to address
fistula include greater investments in health systems and strengthening family
planning programs including those targeting adolescent girls; skilled delivery
care and emergency obstetric care. In addition, the report recommends for
fistula treatment services to be offered for free or at highly subsidized rates
for poor women and girls. See paras. 64(a) – (e).

[42]
Ministry of State for Planning, National Development and Vision 2030,
“Millennium Development Goals: Status Report for Kenya 2007,” 2008,
http://www.planning.go.ke/index.php?option=com_docman&task=cat_view&gid=57&Itemid=75
(accessed December 6, 2009), p. 23.

[43]National
Coordinating Agency for Population and Development (NCAPD) et al., “Kenya
Service Provision Assessment Survey (KSPAS) 2004,” 2005,
http://www.measuredhs.com/pubs/pdf/SPA8/SPA8.pdf (accessed December 10, 2009),
p.111. The KSPAS collected information on health facility infrastructure,
resources, and management systems, and on services for child health, family
planning, and maternal health. Analysis of trends in maternal mortality in
Kenya is complicated by the fact that previous surveys omitted the whole of
northern Kenya and also differences in questions asked. See KNBS and ICF Macro,
Kenya Demographic Health Survey 2008-09, p.273. The Kenya Demographic
Health Surveys have never provided disaggregated data on the MMR.

[44]Ministry
of Health, “National Reproductive Health Strategy (NRHS), 1997-
2010,” 1996, p.29. The NRHS has been revised, and contains the target of
reducing the MMR to 147 by 2015. See Ministry of Public Health and Sanitation
and Ministry of Medical Services, National Reproductive Health Strategy 2009
– 2015, August 2009, p. 65.

[45]
KNBS and ICF Macro, Kenya Demographic and Health Survey 2008-09, pp.
xix-xx. Unmet need for family planning is the gap between women’s desire
to delay or avoid having children and their actual use of contraception. WHO et
al., the Millennium Development Goals Report 2009, p. 23.

[51]
Ibid., p. 116. UNICEF and WHO recommend a minimum of four antenatal visits. WHO
et al., The Millennium Development Goals Report, p.27.

[52]KNBS
and ICF Macro, Kenya Demographic and Health Survey 2008-09, p. 119. This
is a small increase from 42 percent in the 1998 KDHS. WHO defines a skilled
birth attendant as “an accredited health professional—such as a
midwife, doctor or nurse—who has been educated and trained to proficiency
in the skills needed to manage normal (uncomplicated) pregnancies, childbirth
and the immediate postnatal period, and in the identification, management and
referral of complications in women and newborns.” WHO, “Making PregnancySafer: The Critical Role of the Skilled Attendant. A Joint Statement by
WHO, ICM and FIGO,” 2004,
http://whqlibdoc.who.int/publications/2004/9241591692.pdf (accessed March 2,
2010), p. 1. Skilled attendance requires that the health care provider has at
her disposal the necessary equipment and medicines, and a functioning referral
system for emergency obstetric care. Ibid., p. 2.

[53]KNBS
and ICF Macro, Kenya Demographic and Health Survey 2008-09, p. 122. A traditional
birth attendant does not meet the definition of a skilled birth attendant
because they are not formally trained as midwives.

[54]
Ministry of Health and UNFPA, “Needs Assessment of Obstetric Fistula in
Kenya,” 2004, http://www.fistules.org/docs/na_kenya.pdf (accessed
November 15, 2009), p.14. The needs assessment was conducted in Nairobi and
four poor access districts staggered across four provinces. It is unclear how
the number on backlog of cases was arrived at.

[55]For
example Dr. Geoffrey Okumu of UNFPA told Human Rights Watch, “We thought
it [obstetric fistula] was common in poor access districts but it is common in
other areas, for example in Muranga. It may be more widespread than we
previously thought.” Human Rights Watch interview with Dr. Geoffrey Okumu,
fistula program coordinator, UNFPA, Nairobi, November 19, 2009. The needs
assessment quotes a doctor in one of the study districts (Mwingi) saying that
fistula cases are as many as two to three per 100 deliveries in the area.
Ibid., p. 18.

[57]Ministry
of Health, “Community Strategy Implementation Guidelines for Managers of
the Kenya Essential Package for Health at the Community Level,” 2007, p.
23; Ministry of Health, “Linking Communities with the Health System: The
Kenya Essential Package for Health at Level 1: A Manual for Training Community
Health Workers,” 2007, p.3.

[58]
Ministry of Health, “Taking the Kenya Essential Package for Health to the
Community: A Strategy for the Delivery of Level One Services,” 2006,
p.19.

[59]
Ministry of Health, “Community Strategy Implementation Guidelines for
Managers of the Kenya Essential Package for Health at the Community
Level,” 2007, p. 24.

[62]Development
Partners in Health Kenya, “Review of AOP II Implementation – Social
Development Assessment Summary,” October 2007, http://webcache.googleusercontent.com/search?q=cache:oPawE0u4N_IJ:www.hdwg-kenya.com/new/index.php%3Foption%3Dcom_docman%26task%3Ddoc_download%26Itemid%3D%26gid%3D145+Review+of+AOP+II+Implementation+%E2%80%93+Social+Development+Assessment+Summary,%E2%80%9D&cd=1&hl=en&ct=clnk&gl=ke
(accessed January 29, 2010). An NGOimplementing programs on maternal
health in urban slums in Nairobi commented: “During antenatal care we ask
women where she will deliver and she says my husband will know.” Human
Rights Watch interview with [name withheld], Nairobi, December 4, 2009. A nurse
noted, “Many husbands still determine when and where their wives go to
give birth and this is causing many problems for them [pregnant women].” Human
Rights Watch interview with Rose Odeny, reproductive health coordinator, Migori
District Hospital, Nairobi, February 4, 2010.

[64]
In 2007, the Ministry of Health developed Community Strategy Implementation
Guidelines that contain key health messages to be disseminated at the community
level. Under pregnancy, delivery, and childbirth, key messages include danger
signs during pregnancy, but they are not comprehensive. For example, none of
the key messages address the post-partum period. Incontinence, a symptom of
obstetric fistula, is not mentioned. Ministry of Health, “Key Health
Messages for Level 1 of the Essential Package for Health: A Manual for
Community Health Extension Workers and Community Health Workers,” 2007.

[65]
In addition to lack of reliable data on fistula, there is also poor monitoring
of existing programs to be able to determine what, if any, progress is being
made. The head of the Department of Reproductive Health in the Ministry of
Public Health and Sanitation linked this to poor coordination. He remarked,
“I want to stress better coordination. If today as head of the Department
of Reproductive Health I was asked what the statistics are, I don’t
have…. How do we monitor our fistula operations? Are we anywhere near
clearing the backlog? How many surgeries are we doing and are we on track? We
need to publish and share best practices.” Dr. Issak Bashir, speaking at
the Obstetric Fistula Stakeholders’ Meeting, School of Monetary Studies,
Nairobi, February 4, 2009, attended by Human Rights Watch Researcher.

[66]
Obstetric fistula is considered a “near miss” of maternal
mortality, and analyzing its medical, socio-economic, and cultural causes is
critical to improving the quality of maternal care and accountability of the
health care system. The Africa Medical Research Foundation and the Freedom from
Fistula Foundation have been collecting stories of fistula survivors they
support for repairs. Such information, as well as other data, is important in
designing prevention strategies and can be particularly helpful in integrating
fistula into the Community Strategy. The Kenya government should also integrate
inquiries on fistula into future demographic and health surveys.

[67]
Subsequently, UNFPA has supported the government to extend the CMA to four
districts in three provinces as part of the Campaign to End Fistula. WHO, the
UK Department for International Development (DFID), and the United States
Agency for International Development (USAID) also support the government to
expand the CMA. Population Council estimates that by the end of 2008, 24 districts
in Kenya were running community midwifery programs. Ibid., p. ii. WHO, DFID and
USAID have been supporting training of community midwives. UNFPA and Population
Council, “Obstetric Fistula: Can Community Midwives Make a Difference?,”
p. ii.

[68]
For a person to qualify for recruitment as a community midwife, he or she must
meet the following criteria: registered or enrolled nurse midwife; registered clinical
officer (with reproductive health experience); medical practitioner; evidence
of retention on a professional register (Nursing Council of Kenya, Kenyan
Clinical Officers Council, or Medical Practitioners and Dentists Board);
retired or out of employment; obstetric skills; and permanent residency within
the community to be served, or prepared to live in that community. Annie Mwangi
and Charlotte Warren, “Taking Critical Services to the Home: Scaling-up
Home-based Maternal and Postnatal Care, including Family Planning, through
Community Midwifery in Kenya,” 2008, http://www.popcouncil.org/pdfs/frontiers/FR_FinalReports/Kenya_CommMidwife.pdf
(accessed April 6, 2010), p. 7.

[69]
There are no guidelines for charges on the various services offered. Population
Council estimates that the minimum cost of supplies used for the whole package
of care (antenatal care, delivery, and postnatal care is US$15; and that average
profit margin for providing these services is around $5 per client. Community
midwives charge higher fees than health facilities in the provision of certain
services and sometimes even charge for otherwise free services in public health
facilities. However, they accept payment in installments and in kind (for
example exchange of services with farm produce and livestock, labor or
rent-free land). Their services also reduce money and time spent on traveling
to facilities. Ibid., p. 22.

[71]To
receive new stocks of supplies, the community midwife is expected to forward a
report every month showing the utilization and anticipated need for more
commodities. When commodities are not available in the district stores, some midwives
purchase the commodity privately and then provide it at cost to the clients.
Population Council notes that supplies are occasionally hampered by commodity
stock-outs. Ibid., p. 13.

[74]
Traditional birth attendants tend to be elderly women often with no formal
education, in the communities.

[75]As
recommended by the Population Council. Ministry of Health et al.,
“Traditional Birth Attendants in Maternal Health Programmes,” p. 2.
The Community Midwifery Strategy is one such strategy. Although viable, as
earlier noted, the program is fraught with challenges including human resource
and financial ones.

[76]
A study conducted by UNFPA and the Population Council in four districts in
Kenya on the capability of community midwives to prevent obstetric fistula from
occurring concluded that “100% of the women managed by the community
midwives with a diagnosis of obstructed labor were promptly referred and none
developed a fistula.” UNFPA and Population Council, “Obstetric
Fistula: Can Community Midwives Make a Difference?,” p. iv..

[97]Convention
on the Elimination of All Forms of Discrimination against Women (CEDAW),
adopted December 18, 1979, G.A. Res. 34/180, 34 U.N. GAOR Supp. (No. 46) at
193, U.N. Doc. A/34/46, entered into force September 3, 1981, acceded to by
Kenya March 9, 1984.

[98]Convention
on the Rights of the Child (CRC), adopted November 20, 1989, G.A. Res. 44/25,
annex, 44 U.N. GAOR Supp. (No 49) at 167, U.N. Doc. A/44/49 (1989), entered
into force September 2, 1990, ratified December 20, 1990. The Children’s
Act aims to implement international law by “[giving] effect to the
principles of the CRC and the African Charter on the Rights and Welfare of the
Child.” Children’s Act, introduction.

[101] African
Charter on the Rights and Welfare of the Child, OAU Doc. CAB/LEG/24.9/49
(1990), November 29, 1999, ratified July

25,
2000.

[102]
Protocol to the African Charter on Human and Peoples' Rights on The Rights of
Women in Africa (the Maputo Protocol), adopted July 11, 2003, entered into
force November 2005, signed by Kenya December 17, 2003.

[108]See UN Committee on
Economic, Social and Cultural Rights, “Substantive Issues Arising in the
Implementation of the International Covenant on Economic, Social and Cultural
Rights,” General Comment No. 14, The Right to the Highest Attainable
Standard of Health, E/C.12/2000/4 (2000).

[110]
CESCR, General Comment No. 14, para. 12(b). The former UN Special Rapporteur on
the right of everyone to the enjoyment of the highest attainable standards of
physical and mental health, Paul Hunt, developed some indicators to measure
progress with regard to the realization of the right to health. UN Commission
on Human Rights, “Report of the Special Rapporteur on the right of
everyone to the enjoyment of the highest attainable standards of physical and
mental health,” E/CN.4/2006/48, March 3, 2006.

[111]
ICESCR, art. 12.2(a). It states, “The steps to be taken by the States
Parties to the present Covenant to achieve the full realization of this right
shall include those necessary for: (a) The provision for the reduction of the
stillbirth-rate and of infant mortality and for the healthy development of the
child.” According to the UN Committee on Economic, Social and Cultural
Rights, this means to “improve child and maternal health, sexual and reproductive
health services generally, including access to family planning, pre- and
post-natal care,emergency
obstetric services and access to information, as well as to resources necessary
to act on that information.”

[113]
ICESCR, General Comment No. 14, para. 21. The Committee also states that
“It is also important to undertake preventive, promotive and remedial
action to shield women from the impact of harmful traditional cultural
practices and norms that deny them their full reproductive rights.”Ibid.

[125]UN Commission on Human Rights, “The right of
everyone to the enjoyment of the highest attainable standard of physical and
mental health. Report of Special Rapporteur, Paul Hunt, submitted in accordance
with Commission resolution 2002/31”, E/CN.4/2003/58, February 13, 2003
and CEDAW Committee, General Recommendation No. 24, para. 18.

[131]
UN Human Rights Committee, General Comment 31: Nature of the General Legal
Obligation on States Parties to the Covenant, U.N. Doc. CCPR/C/21/Rev.1/Add/13
(2004), para. 15.

[132]
Human Rights Council, Report of the Special Rapporteur on the Right of Everyone
to the Enjoyment of the Highest Attainable Standard of Physical and Mental Health,
A/HRC/7/11, January 31, 2008, http://daccessdds.un.org/doc/UNDOC/GEN/G08/105/03/PDF/G0810503.pdf?OpenElement
(accessed April 9, 2010), para.30.

[133]
Office of the High Commissioner for Human Rights, “Claiming the
Millennium Development Goals: A human rights approach,” 2008, www.ohchr.org/Documents/Publications/Claiming_MDGs_en.pdf(accessed September 28, 2009), p. 15.

[134]Human
Rights Council, Report of the Special Rapporteur on the right to health, para.
99.

[140]
The director of Public health has been quoted saying that opposition from
parents, religious groups and some civil society bodies had led to a
“censored sex education campaign” in schools. Irin PlusNews,
“Kenya: Back-street Abortions Underline Need for Sex education,” October
19, 2009, http://www.plusnews.org/report.aspx?ReportId=86641 (accessed July 1,
2010). A study by the Centre for the Study of Adolescence—an NGO that has
been conducting sexuality and HIV/AIDS education in primary and secondary
schools in Kenya—looking at the implementation of the Ministry of
Education’s Return to School Policy to enable girls who get pregnant return
to school after delivery, criticizes the government for lack of comprehensive
sexuality education in schools despite the government being aware of such a
need. The study further says, “[o]pposition from religious and community
leaders as well as policy and decision makers has often been a major barrier,
preventing young people from accessing information and services, which would
enable them meet their sexual and reproductive health needs.” Rosemarie
Muganda-Onyando and Martin Omondi, “Down the Drain: Counting the Costs of
Teenage Pregnancy and School Drop Out in Kenya,” 2008, http://www.csakenya.org/pdfs/CSA%20Pregnancy-FINAL%202-EDITED.pdf
(accessed July 1, 2010), p. 31.

[143]
Human Rights Watch phone interview with James Kiprotich, high school teacher,
June 25, 2010.

[144]See, National
Council for Population and Development and Department of Reproductive Health,
“Adolescent Reproductive Health Development Policy,” 2003; Ministry
of Health, “National Guidelines for Provision of Youth-Friendly Services
(YFS) in Kenya,” July 2005; Ministry of Public Health and Sanitation,
“National School Health Policy,” 2009; and Division of Reproductive
Health et al., “Adolescent Reproductive Health and Development Policy
Plan of Action 2005-2015,” August 2005.

[145]Ministry
of Public Health and Sanitation and Ministry of Education, “National
School Health Policy,” and Ministry of Public Health and Sanitation and
Ministry of Education, “National School Health Guidelines,” 2009.

[146]
For example, Rosemary Muganda-Onyando, director of the Centre for the Study of
Adolescence commented, “teachers are not well-informed to provide
sexuality education, besides there are no detailed guidelines provided.”
Muthoni Ndungu, coordinator of the Reproductive Health and Rights Alliance also
noted “The subject [sexuality education] is not examinable so it’s
up to the teacher to plan when to teach. There is no accountability to ensure
teachers are actually teaching.”[146]
Human Rights Watch interviews with Rosemarie Muganda-Onyando, Nairobi, December
2, 2009, and Muthoni Ndungu, Nairobi, December 3, 2009.

[151]
The 2008-09 KDHS indicates although that there is widespread awareness about
different methods of family planning, “Exceptions are found among women
with no education, women in the lowest wealth quintile, and women in North
Eastern province, where less than half of married women have heard of anymethod. It
further notes: “There is a sharp contrast between urban and rural areas
in exposure to family planning messages through television and print media. For
example, 64 percent of women and 60 percent of men in urban areas are exposed
to family planning messages through television, compared with only 29 percent
of women and 31 percent of men in rural areas.” KNBS and ICF Macro, Kenya
Demographic and Health Survey 2008-09, pp. 58 and 72.

[156]
Population Council, “Acceptability and Sustainability of the WHO Focused
Antenatal Care package in Kenya,” 2006, http://www.whiteribbonalliance.org/Resources/Documents/Acceptability%20and%20Sustainability%20of%20WHO%20FANC%20in%20Kenya_USAID.pdf
(accessed April 9, 2010), p. 34. Focused antenatal care (FANC) is an approach
to antenatal care that emphasizes a comprehensive approach to pregnancy and
childbirth through early detection and treatment of problems and complications
through prevention of complications and disease, birth preparedness and
complication readiness, and health promotion. FANC is individual woman-centered
and a skilled health provider should attend to the women. See Access to
Clinical and Community Maternal, Neonatal and Women’s Health Services
(accessed march 31, 2010), “Focused Antenatal Care: Providing Integrated,
Individualized Care During Pregnancy,” http://www.accesstohealth.org/toolres/pdfs/ACCESStechbrief_FANC.pdf
(accessed may 3, 2010).

[161]
Human Rights Watch interviewed women who had lived with fistula for various
lengths of time: 45 years to one month.

[162]One
woman told us “I thought it is something that happens when one gives
birth,” and another, “I waited for two months before going to Wote
[health facility] because I thought the problem would go away.” A nurse
told us, “Many of the women and girls I have interacted with during this
camp and the camp in October think it [fistula] is a ‘natural outcome of
delivery.’” Human Rights Watch interviews with Nduku K., Machakos,
December 6, 2009; Mueni M., Machakos, December 6, 2009; and Lilian Ndege, nursing
officer in charge of the gynecology ward, Kisii General Hospital, Kisii, November
11, 2009.

[163]
Almost a quarter of the women and girls interviewed by Human Rights Watch said
this.

[164]When researchers
asked Fatuma H. why she had not sought treatment for fistula she told us, “I
didn’t know that a bladder can be repaired.” Nekesa U. told us that she had a difficult time convincing her husband to take her to the fistula camp
for surgery: “People told my husband … ‘that woman cannot
heal because there is no way you can stitch the bladder. It’s a lie. They
want to eat your money.” Human Rights Watch interviews with Fatuma H.,
Kisumu, December 9, 2009, and Nekesa U., Kisumu, December 9, 2009.

[167]
For example, Beatrice N. told us, “When I was leaving the hospital the
water [urine] was coming out but the doctor didn’t tell me what it was.
He just told me to go and buy medicine and come back after four months.”
Wairimu K. remarked, “I stayed in the hospital for two weeks after giving
birth but I was not told what my illness was.” Human Rights Watch
interviews with Beatrice N., Kisii, November 11, 2009, and Wairimu K., Kisumu,
December 9, 2009.

[168]Nurses
are required to talk to patients about potential complications during FANC. An
evaluation by Population Council found that clients do not receive all the
required information and that “Providers consistently provided selective
information, thus undermining the comprehensiveness of focused ANC. Population Council,
“Acceptability and Sustainability of the WHO Focused Antenatal Care
package in Kenya,” p. 32. The 2004 Kenya fistula needs assessment report
also notes that health providers do not talk about obstetric fistula during
health talks in hospitals. Ministry of Health and UNFPA, “Needs
Assessment of Obstetric Fistula in Kenya,” p.20.

[170]The 2004 Kenya Service
Provision Assessment Survey found that medical providers were lacking in
knowledge not only about new methods, but also about basic information critical
to providing quality maternal health care. For example, only 6 percent of
midwives interviewed for the survey could name all four categories of the signs
of postpartum hemorrhage and only 12 percent of midwives were able to name all
four expected interventions for postpartum hemorrhage, while guidelines for
managing delivery complications were available in only 7 percent of facilities.
NCAPD et al., “Kenya Service Provision Assessment Survey 2004,” p.
132. Moreover, in fewer than one-third of facilities had the majority of
providers received any structured training relating to delivery services during
the past year, and only 8 percent of providers had received routine training on
life-saving skills. Ibid., pp. 144-45.

[177]UN
General Assembly, “Note by the Secretary-General: The Right of Everyone
to the Enjoyment of the Highest Attainable Standard of Physical and Mental
Health,” 13 September 2006, A/61/338, para. 14. It states, “While
the right to health includes entitlements to specific health-related goods,
services and facilities, it should also be understood more broadly as an
entitlement to an effective and integrated health system, encompassing health
care and the underlying determinants of health, which is responsive to national
and local priorities, and accessible to all.”

[178]See
Family Health International, “The Importance of Family Planning in Reducing
Maternal Mortality,” undated, http://www.fhi.org/en/RH/Pubs/Briefs/MCH/factsheet11.htm
(accessed May 20, 2010). A study conducted by the Guttmacher Institute and
UNFPA estimated that if countries invested in family planning, unintended
pregnancies would drop by more than two thirds, 70 percent of maternal deaths
would be averted (a decline from 550,000 to 160,000), 44 percent of newborn
deaths would be averted (a decline from 3.5 million to 1.9 million), unsafe
abortions would decline by 73 percent (from 20 million to 5.5 million, assuming
no change in abortion laws), and the healthy years of life lost due to
disability and premature death among women and their newborns would be reduced
by more than 60 percent. S. Singh et al., Adding It Up: The Costs and
Benefits of Investing in Family Planning and Maternal and Newborn Health (New
York: Guttmacher Institute and United Nations Population Fund, 2009), p. 4.

[185]
For example see, Joyce Mulama, “One Nurse, One Dispensary, 9,000
Patients,” Saturday Nation, July 3, 2010. In this article, the
author visited a dispensary in Turkana, a rural and poor region in Northern
Kenya. It quotes the only medical staff at the facility saying, “I am
everything in this [dispensary]. I do the clerking, examination of patients,
dispensing drugs, stitching cuts, antenatal care and even delivery [of]
babies.”

[186]Ministry
of Public Health and Sanitation and the Ministry of Medical Services,
“Health Care Financing Policy and Strategy: Systems Change for Universal
Coverage,” November 2009, p.6.

[190]
NCAPD et al., “Kenya Service Provision Assessment Survey 2004,” p.
30. It is possible that the catchment areas of government and nongovernment facilities
overlap, since government catchment areas are constructed to serve the entire
population, whereas nongovernmental facilities define their own catchment
areas, usually without coordinating with the government. However, the problem
of facilities being overstretched remains.

[191]
Ibid., p.128.The survey
noted that the percentage of facilities offering normal delivery services in
2004remained relatively similar to that observed in 1999.

[193]
The World Bank has estimated that if all women had access to emergency
obstetric care, 74 percent of maternal deaths could be averted. Millennium
Project, Task Force on Child Health and Maternal Health, Who’s Got the
Power?, p. 5.

[196]Ibid. The
overall coverage for comprehensive emergency obstetric care is nearly two facilities
per 500,000 population, but wide regional differentials exist. At the time the
KSPAS was done, the recommendation for the mixture of basic and comprehensive emergency
obstetric care facilities per 500,000 population was at least one comprehensive
and four basic emergency obstetric care facilities per 500,000 population. This
has been revised to at least five emergency obstetric care facilities including
at least one comprehensive facility per 500,000 population. See, WHO et al., Monitoring
Emergency Obstetric Care: A Handbook, (Geneva, WHO Press, 2009), p. 5.

[197]NCAPD et al., “Kenya
Service Provision Assessment Survey 2004,” pp. 146-147. Emergency
obstetric care involves a set of services or interventions called “signal
functions” that should be available in a facility that provides emergency
care for women with pregnancy-related complications. These “signal
functions” are proven to significantly reduce maternal deaths and improve
birth outcomes for the newborn, and they must be performed at a facility in
order for that facility to be recognized as an emergency obstetric care
facility. A facility can either be classified as a basic emergency obstetric
care or a comprehensive emergency obstetric care facility. The basic emergency
obstetric care signal functions are seven and include: administration of
parenteral antibiotics, oxytocic drugs (drugs that expand the cervix or vagina
to facilitate delivery), and anticonvulsants; manual removal of placenta;
manual vacuum aspiration of retained products of conception; assisted vaginal
delivery, and basic neonatal resuscitation. Comprehensive emergency obstetric
care includes the seven basic signal functions, plus performing surgery (for
example, cesarean section), and blood transfusion. See WHO et al., Monitoring
Emergency Obstetric Care: A Handbook (Geneva: WHO Press, 2009).The earlier
guidelines did not include basic neonatal resuscitation in the basic services
category. In addition, the name of the second signal function has been changed
from “administer parenteral oxytocics” to “administer
uterotonic drugs.” Ibid., pp. 6-7. At the time the service provision
assessment survey was done, the earlier, 1997, guidelines were in use.

[198]According
to the 2008-09 KDHS, 43 percent of rural women say they did not deliver in a
health facility because it is too far or due to lack of transport. KNBS and ICF
Macro, Kenya Demographic and Health Survey 2008-09, p., 121.

[200]The
KSPAS noted that only 27 percent of all facilities—and barely half of
facilities specifically offering delivery services—have the ability to
provide emergency transportation to another facility for obstetric emergencies.
NCAPD et al., “Kenya Service Provision Assessment Survey 2004,” p.
130. Even when a facility does not offer delivery services, but does offer antenatal
care, it is desirable to have emergency transport available because in most
cases, especially in the rural areas, the facility where a woman receives antenatal
care may be the nearest formal health sector site from which emergency help can
be sought.

[205]
Ministry of Public Health and Sanitation and Ministry of Medical Services,
“Referral Strategy and Investment Plan for Health Services,” July
2008-June 2012, p. 22.

[206]
Ministry of Health, “Community Strategy Implementation Guidelines for
Managers of the Kenya Essential Package for Health at the Community
Level,” p. 34.

[207]Almost
all the doctors we interviewed told us fistula is a disease of the poor and
therefore one cannot make money from being a fistula surgeon. Most doctors in
Kenya operate private clinics; most fistula survivors cannot afford the high
charges.

[209]UNFPA,
through the global Campaign to End Fistula, funds the Kenya government for
fistula repair camps in selected district and provincial hospitals. Each of the
hospitals holds one camp per year. In addition to the fistula clinic they
support at KNH, AMREF also provides financial support for fistula camps at
selected district and provincial hospitals. Both AMREF and UNFPA also provide
supplies and equipment for fistula surgery to hospitals. Other organizations
that support fistula repair work include the Freedom from Fistula Foundation,
the Safaricom Foundation, MSF Spain, and Women and Health Alliance
International.

[218]The National Hospital Insurance Fund was established in 1966. It currently
covers around 25 percent of the population. The scheme is mandatory for those
in the formal sector and voluntary for those in the informal sector. Ibid., p.
11.

[219]For
more discussion on the NSHIF, see Diana N. Kimani et al., Healthcare
Financing Through Health Insurance in Kenya: The Shift To A National Social
Health Insurance Fund, KIPPRA Discussion Paper No. 42 (Nairobi: Kenya
Institute for Public Policy Research and Analysis, 2004).

[220]
See International Budget Partnership, “Civil Society Budget Analysis and
Advocacy as a Tool for Maternal Health Accountability,” September 7,
2009, http://www.eurongos.org/Files/HTML/EuroNGOs/AGM/IBP_presentation_EURONGOsConf_FINAL.pdf
(accessed June 25, 2010).

[227]
There is a lack of sufficient research on how well women reintegrate after
fistula surgery, as well as models for reintegration and rehabilitation. In the
experience of providers and advocates in Ethiopia, Nigeria, and Tanzania,
totally cured women can and do reintegrate back into their community and are
able to carry on with life, including remarrying and having further
pregnancies. However, WHO cautions that, “While it appears that
successful repair may well lead to a smooth transition/reintegration when
returning home; further research is needed to identify specific challenges to
the quality of life of these women and the degree to which they are
reintegrated.” WHO, Obstetric Fistula: Guiding Principles for Clinical
Management and Programme Development, p. 12.

[231]See
Ministry of Public Health and Sanitation and the Ministry of Medical Services,
“Health Care Financing Policy and Strategy,” pp. 9-11. Human Rights
Watch has previously written about inability of poor families to access health
care due to financial constraints. See Human Rights Watch, A Question of
Life and Death: Treatment Access for Children Living with HIV in Kenya (New
York: Human Rights Watch, 2008), p. 45.

[233]
WHO for example has argued that, “One of the keys to improving
women’s health therefore, is the removal of financial barriers to health
care…. Evidence from several countries shows that removing user fees for
maternal health care, especially for deliveries, can both stimulate demand and
lead to increased uptake of essential services. Removing financial barriers to
care must be accompanied by efforts to ensure that health services are appropriate,
acceptable, of high qual­ity and responsive to the needs of girls and women.”
See WHO, Women and Health: Today's Evidence Tomorrow's Agenda (Geneva:
WHO, 2009), http://whqlibdoc.who.int/publications/2009/9789241563857_eng.pdf
(accessed November 24, 2009), p. xiv.

[236]
Minister Charity Ngilu argued against cost-sharing and tried to introduce a
social health insurance bill in parliament, but it did not get a presidential
assent “as it failed to provide a credible roadmap on implementation,
affordability for the poor and viability of the system.” See Ministry of
Public Health and Sanitation and the Ministry of Medical Services,
“Health Care Financing Policy and Strategy,” p.2. These efforts are
still ongoing.

[237]
According to the 2008-09 Kenya Demographic and Health Survey, 72 percent of
women who obtain contraceptives from the public sector paid some fees, although
it does not define what fees were paid. KNBS and ICF Macro, Kenya
Demographic and Health Survey 2008-09, p. 68. The 2004 Kenya Service
Provision Assessment Survey had found that, “Overall 23 percent of family
planning facilities charge fees for maintaining the client record; 19 percent
charge for the family planning consultation, and 24 percent charge for the
contraceptive method itself.” NCAPD et al., “Kenya Service
Provision Assessment Survey 2004,” p. 9.

[244]
The policy says that the “Decision for granting a waiver of not should be
based on history taking and close observation of the socio-economic status of
the patient and his/her relatives.” Division of Health Care Financing,
Ministry of Health, “Facility Improvement Fund, Supervision
Manual,” p. 21. Other information to be noted include occupation, number
of children, means of transport, alcohol and cigarette consumption, and type of
clothing. Ibid., p. 21.

[245]
Division of Health Care Financing, Ministry of Health, “Facility Improvement
Fund, Supervision Manual,” p. 21. The policy says that all health
facility staff should be informed about the operation of the waiver system, and
that all patients should be about the waiver system. Ibid.

[252]Ministry
of Public Health and Sanitation and the Ministry of Medical Services,
“Health Care Financing Policy and Strategy,” p.11.

[253]See Sharma et al.,
“Formal and Informal Fees for Maternal Health Care Services in Five
Countries,” p. 2, discussing providers’ lack of awareness about
which services are exempted or how the waiver system works.

[254]
Helen Potts, “Accountability and the Right to the Highest Attainable
Standard of Health,” 2008, http://www.essex.ac.uk/human_rights_centre/research/rth/docs/HRC_Accountability_Mar08.pdf
(accessed October 30, 2009), p.3.

[255]
See FIDA Kenya and Center for Reproductive Rights, “Failure to Deliver:
Violations of Women’s Human Rights in Kenyan Health Facilities,”
2007, (accessed November 4, 2009). Human Rights Watch spoke to six women, who
had given birth within a range of 20 years to 3 months from the time of the
interview, who said they had been verbally and physically abused by health
providers while in labor. One of them Awino A. who had labored at home for more
than 15 hours before going to the nearest district hospital told us, “We
arrived at the hospital around midday. Two nurses took me to the labor ward and
they kept telling me to push. After sometime they left me alone. Occasionally,
a nurse would come by and hit me telling me I got pregnant because I enjoyed
sex and if I don’t push I will kill my baby. They would slap and pinch my
thighs.” Seventeen-year-old Monica E. told us, “I was in so much
pain when we arrived at the hospital. The nurse who took me to the labor ward
told me, ‘stop behaving as if you are in pain because this is what you
were looking for. Why was a young girl like you having sex?’”Two
other girls said that when they expressed pain, nurses had told them not to
pretend to be in pain because they had enjoyed the sex. Human Rights Watch
interviews with Awino A., Nairobi, November 26, 2009; Monica E., Nairobi,
December 2, 2009; Eunice F., Kisumu, December 9, 2009; and Monica J., Nairobi,
December 2, 2009.

[262]National Joint Steering Committee for Maternal Health
Kenya, “Standards for Maternal Care in Kenya,” 2002, p.3. The
Standards were developed by the National Nurses Association of Kenya and the
Kenya Obstetricians and Gynaecologists Society and are focused on provision of
emergency obstetric care in hospitals and health centers. A partograph is a
graphical record of progress during labor. Progress is measured by cervical
dilation against time in hours. As well the partograph provides a record of the
important conditions of the mother and fetus that may arise during the process
of labor. The partograph is a useful tool for managing obstructed labor. Skilled
practitioners can use it to recognize and deal with slow progress before labor
becomes obstructed and if necessary, ensure that Caesarean section is performed
on time to save the mother and the fetus. WHO, “Maternal Mortality: Fact
Sheet,” 2008, http://www.who.int/making_pregnancy_safer/events/2008/mdg5/factsheet_maternal_mortality.pdf
(accessed May 12, 2010), p. 2.

[271]Ministry
of Health, “Service Charter for Health Service Delivery,” 2006, www.medical.go.ke
(accessed January 20, 2010), p. 5. The Rights mentioned in the charter include,
right to care by qualified health provider, right to accurate information, right
to timely service, right of choice of health provider/service, right to
protection from harm or injury, right to privacy and confidentiality, right to
courteous treatment, right to dignified treatment, right to continuity of care,
right to personal/own opinion, right to emergency treatment anywhere, and right
to dignified death.

[272]Ministry
of Public Health and Sanitation, “Citizens Service Delivery Charter,”
www.publichealth.go.ke, (accessed January 20, 2010).

[273]
Ministry of Medical Services, “Citizens Service Charter for Delivery of
Medical Services for District Hospitals,” undated.

[276]Human
Rights Watch interview with Esther Mbinzi, nurse in the gynecology ward,
Machakos General Hospital, Machakos, December 6, 2009. The patient’s
rights charter seen by Human Rights Watch was an A4 size document in English.
It is highly unlikely patients will see it, and many may not speak English or
be literate.

[289]Ministry of Medical Services and Ministry of Public Health and
Sanitation, “National Road Map for Accelerating the Attainment of the
MDGs Related to Maternal and Newborn Health in Kenya,” March 2009, p. 13.

[291]
Ministry of Health, “Family Planning Guidelines for Service
Providers,” March 2005.

[292]
See Division of Reproductive Health, “National Guidelines for Service
Providers,” 2010.

[293]
National Council for Population and Development, Ministry of Planning and
National Development/Department of Reproductive Health (DRH), Ministry of
Medical Services, “Adolescent Reproductive Health and Development
Policy,” 2003, p.15.